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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT.• <br />Date %/i AZ _ <br />To-, San Joaquin County <br />/Department of Public Works <br />K+f"" <br />(Applicant Name) <br />ori �. / i . <br />(Malling)Address) <br />SW.LkL. Gta Q 1"2)5 <br />(City, State, IJp Code) <br />4166 ra%(o— 17Co7 <br />(Area Code - Telephone�"^ber) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />x <br />e <br />Er? L <br />JOB <br />OFFICE USE ONLY <br />REF <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />CR p <br />TO DRIVEWAYS. <br />AREA <br />TYPE <br />QUAD <br />FORMS <br />NOTES <br />The undersigned hereby applies for permiss o excav�7le, Fonstrucl and/or otherwise encroach on County High Right -of -Way on <br />the //�/t�� sidegf Su -t -)r %�d apprommalety ( \'U �i"mile'_ <br />Of ( , by performing the following work (description of work)' <br />Work will commence on or after — for approximately ! days. <br />I, the undersigned, certify that I of the respective property, or am qualified to represent the owner and agree to do the <br />work described above In ac9oltiance with the Oes and regulations of San Joaquin County and subject to inspection and approval. <br />Z <br />Date <br />