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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 331��' OFFICE USE ONLY <br /> To: San Joaquin County JOB# [JQ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 <br /> Nprw � ��nC . VALID T p DRIVEWAYS: <br /> (Applicant Name) STREET (,L NToN AJC.Soyr . ELGD IR49! <br /> �) AREA ie 1 Pok QUAD iq e k <br /> PC) TYPE MP ftoAa G.OSU 9-6- <br /> (Mailing <br /> E(Mailing Address) FORMS <br /> ��� NOTES <br /> C,f4Lo TNfcSICIES ;t IOK er! <br /> (City,State,�Zii fp Crode) o 14 :oo A fit. Td <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> set 91W" <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the followiing work(description of work): <br /> L' c&.LYe- O (NVQ (NNe l to fr vc— —jar Cl*—h Anft w1 <br /> Work will commence on or aboutIl for approximately!7% To : 6 J?o'I, days. <br /> If 0 <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 /> Signature o Appl ant-Title Date <br /> M'ICENTRAISERVICESICLERICALIPURSV.WKUMSTERPSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />