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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f#" ��� _ % q OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID -7-2-9-If TO -lS- ¢ DRIVEWAYS: <br /> (Applicant Name) STREET fy� <br /> AREA 5�CIM QUAD S E <br /> IW Lr,Ls4 -sl- TYPE <br /> (Mailing Address) FORMS Sq IkZ W gZ 5 <br /> ex NOTES <br /> (City, Siate,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig;—e5 ight-of-Way on <br /> the ,�s f side of ��cEN C.j.! C;4 1� 1 —approximately JO C-0 ile rJ Gr N <br /> of �' rY le <br /> . ��ToCkd� by performing the following workcripfion of work): <br /> Gls F'rDAr � N^t E ry .' g �s :'✓C �v a, �'i// Z/QS4r L / 2- <br /> Work will commence on or about ) ;�f— �y _for approximately '30 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 /> �4 <br /> ture of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB&SV WKIMASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />