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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Wo r s ! APN CR# <br /> EXP.DATE <br /> VALID -,5= ' -4TO DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> ®� AREA QUAD S <br /> Av <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> Lin) V10 - D 'l2 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for perms sion e <br /> to excav t ,construct and/or otherwise encroa on County HighwayRight-of-Way n <br /> � <br /> th'bVti� A- side of 4. 'V d V1 ; iM approximately �U17 t/mile <br /> of 41.1 [4V SOtn V=1 ctrl ?(AS Vt,(. V\VffskA/k, aka,by performing the following work(description of work): <br /> V bqb0f, SMMe WVA I -t/kI Vw) iAYawvVAWA�Wylno18s41(VA 9N� <br /> Work will commence on or about for approximately day . <br /> I,the undersigned,certiy 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 .cc anV <br /> Vwith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> LL <br /> YO <br /> Signature of Applicant-Title Date <br /> MICENTRALSERVICESICLERICALIPI/BSV.WKURASTER.PSVENCROACRMENTPERMITAPPLICATION.00C (0911) <br />