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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � 2(, I q OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7,3 C)C)ZZ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> / VALID 2114- TO DRIVEWAYS: <br /> (Applicant Name) STREET Airjmrt cx y ,,rl d <br /> AREA 4f, ��;�,, QUAD <br /> lD l / ('P TYPE �Sr�/f- <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City�e,Zip ode) 3 <br /> "5 -)9- - -)-I'L5�z <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> C1-/1The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -D . sideof`S l ,'��o�Lf'r�c�_ approximatelyle e mile„ <br /> Of �,�� , :5 -/ �C/�� � �frr�+�`�-�, by performing the following work description of work): <br /> mo L-0 t ho)) <br /> Work will commence on or about `7 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -� 2 � /�— <br /> Signature of Applicant-Title Date <br /> rec lever/i USI 4 <br /> M ICENTRALSERVICESICLERICAl1PUBSY.WNIMASTER.PSIENCROACRMENTPERMR APPLICATION DOC (09/13) <br />