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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ti ��/ J OFFICE USE ONLY <br /> To: San Joaquin County JOB# (re 7jDZ-f bREF# <br /> Department of Public Works APN CR# <br /> -i� EXP.DATE <br /> ro �N Jf t� ( �� VALID DRIVEWAYS: <br /> c (Applicant Name) STREET <br /> nI � i AREA QUAD <br /> t <br /> �i?( Iffy�'b)I `�4' � 1.� "' Y �� TYPE <br /> (Mailing Address) FORMSRZ9 <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for fission to excavate,construct ndlor otherwise encroach on County Highway Right-of-Way on <br /> the side of L,�1 CALF-�m> Imo) a{� "ima r� -feeHt file !� <br /> Of X-�cu by performing the following work(description of work): <br /> op £(N-57 ()✓ h 14 A5 LuJ , L.- o- _ .- "10 t ����►1G'Iij �1 <br /> �. �!✓� � t`� l�4� CrV L� t3� II f�h1� bih - � i <br /> Work will commence on or about for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described abovaccor nce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> c� 2 1711 <br /> Signature of Apf licant--f itle bate <br /> M:ICENTRALSERVICESICLERICAi1PUB-SV.WKWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (09113) <br />