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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1jo if, 1x10o5 2( <br /> Date 6/U/14— OFFICE USE ONLY <br /> To: San Joaquin County JOB# ^PREF# <br /> Department of Public Works APN CR# <br /> EXP.DATE (() 1-2-0 t�A <br /> J u�✓►1 Or^��y VALID Z2_,-2C-jTO Q- Zu DRIVEWAYS: <br /> (Applicant Name) STREET .;�,, �- <br /> AREA v. QUAD <br /> $ ' Il �ur� etC� E•3 TYPE 'YE� U► 1� .,I <br /> (Mailing Address) FORMS jV=2�Z <br /> NOTES <br /> 37 2D <br /> (City,State,Zip Code) <br /> �qz5) 32,7- 0910 <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 Highway Right-of-Way on <br /> the 15-AAh side of 3o09 -- i&e, Avy—. approximately 7-14- 1=ire-f feet/mileANW Q`*- <br /> of 5L&1; '�-` '1`d- by performing the following work(description of work): <br /> Work will commence on or about —C)I-I for approximately days. <br /> I,the undersigned,certify th m the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described abo ' ccor nce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> S• n o pplicant-Title Date <br /> M.\CENTRALSERVICES\CLERICAL\PUB-SV.WN`MASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/19) <br />