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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11 n O Q 5 REF# <br /> Department of Public Works APN CR# <br /> Ir" EXP.DATE q-1 - <br /> VALID -7-14-10t TO 91- 1 -1-f <br /> DRIVEWAYS: <br /> (Applicant Name) STREET CLI er6 tc,tc Rd <br /> AREA 51 IN QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) r y <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way o <br /> the �A`'T side of C A€=f.6 ic,6E- r-15 approximately, � 1 ' fee mile / 11 N <br /> Of T`61r-:'r E C-- 6 sb . �=>i c��.-+�To by performing the following work( escription of work): <br /> Work will commence on or about `7— P- for approximately 'F,LO - 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 /> i ature of Applicant-Title Date <br /> M'.ICENTRALSERVICESiCLERICALIPUB-SV.WNIMASTER.PMENCROACHMENT PERMIT APPLICATION DOC (09113) <br />