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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB# 2a ( REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE y l- <br /> 4%A4Y �c,,,(VSJPZFMAORS` VALID 7 _ ¢ TO c(_/ -d ye DRIVEWAYS: <br /> (Appli ant Name) STREET <br /> IN <br /> ��pp AREA 7QUAD <br /> �r of I� Aik TYPE T- <br /> (Mailing Address) FORMS L >cJ <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies forermission to excavate,construct and/or otherwise encroach on County HigNedymile <br /> Right-of-Way on <br /> the side of Vvgc%�, 5J approximately ca <br /> of c A1411L a l0;. "Z L by Derformina the following wok a cription of work): <br /> koE <br /> Work will commence on or about 1 ILIfor approximately_ 0 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 /> Signature of Applicant-Title Date <br /> K10ENrRALSERVICESICLERICALNUBSV.WKIMASTER.PSIENCROACNMENTPERMFTAPPUCATION.DOC (09/13) <br />