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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -7 —/Q �-� OFFICE USE ONLY <br /> To: San Joaquin County <br /> JOB# REF# <br /> Department of Public Works APN CR# <br /> C N J�J,�� �c�- � � � VALID ATE • ' �O DRIVEWAYS: <br /> (Applicant Name) STREET }K-• <br /> AREA QUAD w <br /> /Z/5Af`, TYPE e— <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 47 2- 7 93- y t'�r77 <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 High Right-of-WawY <br /> yon--- <br /> The <br /> the N D�7 N side of 7�"N approximately fee ile ` <br /> of .Soo. 4 7, � ��1�T P ) a ,by performing the following work( escription of work): <br /> , rum AIL � > ������t 1` F�� �I<'i✓ �n+'�� <br /> Work will commence on or about for approximately i 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 /> Sig at a of Applicant-Title Date <br /> MICENTRALSERMCESCLERICAL\PUBSV.WKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />