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APPUCATICN FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> PS ( 101 676 4 R I �---- <br /> Date �Q-� I y OFFICE USE ONLY <br /> 10: San Joaquin County JOB# -7kQ7 7 REF# <br /> Department of Public Works APN CR# <br /> WJ9 _ EXP.DATE! 10 - ( -� A 1 A I ER.c�`L011E VALID 2 - 16-14 . TO DRIVEWAYS: <br /> (Applicant Name) STREET (oo/!rl'a P A <br /> _ AREA >-f lon QUAD C– <br /> (0r�i E j.f� l� �� t ST TYPE <br /> C (Flailing Address) FORMS / 2 <br /> )'S�� -NOTES <br /> � `� <br /> (City,State,Zip Code) <br /> (Area Code o Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa �ile <br /> ight-of Wa on <br /> the side of >c>);r, approximately ee k <br /> °f by performing the following work( escription of work): <br /> Work will commence on or about 1 —f r a roximately da s. <br /> CQJ)5�r` y <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualitie 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 of <br /> 9 Applicant Titie qtr <br /> M-'IrEMRALSERNCES1CLEPJCAUPUBSV.WKN7ASTEFLps ENCROACH%,EMTPERAIRAPPLICATIONAOC(09/1 <br /> 1 <br />