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APPLICATION FOR ENCROACHMENT PERMIT <br /> ( <br /> PLEASE PRINT: <br /> Date E .i/. ` OFFICE USE ONLY <br /> J P <br /> To: San Joaquin County JOB# /Q REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ / <br /> SCS f�� C i A a I's ��� 1 Y J VALID T � DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA -JA-#ey QUAD <br /> - - ,,3`/v 6,e-16 5 T. TYPE -SELLko+:b,/I�aT+IacES- 2 -� <br /> (Mailing Address) FORMS <br /> NOTES �— <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) — ra> <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of- ay <br /> on <br /> the 6a"T H side of 6. GN c-t C.i.0 approximately feettmile_60-01- <br /> 1tr-�c--Y by performing the following work(description of work : <br /> L c:p --.eo A,, E Kf�Sy i IA—)e , CAT v V A c,J i i cd J,sr'l-Z 4�- <br /> .2; eC c)fJ 1�t! 1 T FO�-7, 9 l7-V'C C —� <br /> Work will commence on or about for approximatelyS ay <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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sh nature of Applicant-Title Date <br /> M:ICENTRALSERVICES)CLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />