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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> —' OFFICE USE ONLY <br /> Date /— ( ,I— 1 (--t <br /> To: San Joaquin County JOB# �� � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /s 201 V <br /> C N 01S; T&e-f� ( Ge�rjco) VALID -] ,�� ?�at�`�0 S��/�-Z0�y DRIVEWAYS: <br /> (Applicant Name) STREET <br /> f AREA UADj <br /> 573'/0 0 cSA SK, TYPE Y <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> - - -------------------------- <br /> -------------------- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-ofi-WaY <br /> the N0�9 side of .5'r*' �� -approximately `7 (D— fee mile l�S <br /> of S o: +?` 1 M : S'7r. aTC�r c Tc3 ,by performing the following work description of work): <br /> 1-a fLE F're-e>M .rQ 162 7-0 `25 0,N) ��.S"-r To J-0/1­11 F'o t V <br /> o t J IN,1 At_L �- �!"• <c)IJ t'��1/T v►'� �'rIG!'�I/ 'Gs._ ►G <br /> Work will commence on or about :7-a for approximately i S —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 /> ign ture Applicant-Title Date <br /> M'ICENTRALSERMCESICLERICALIPUBSV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.000 (09113) <br />