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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date V1712 -Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# Q ` y _ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE h/S-ZU[Lt <br /> VALID TO DRIVEWAYS:/- - L� ((i r its-�v) <br /> (Applicant Name) STREET <br /> AREA6r <br /> TYPE C��r�'QUAD LL <br /> (Mailing Address) FORMS <br /> -, NOTES <br /> (City,State,Zip Code) -- - - - <br /> (Area—Code­-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> h/-��/� :�/� //✓CSG���.� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroachaiC inty Hi -of-Way on <br /> the /�fJ�Tsip- side of ` mately %6le Right <br /> !L �% 11MI-11o, <br /> pproxi <br /> U ghway way ig <br /> by performing the following work(description of work): <br /> T <br /> AA ,J 12 <br /> Work will commence on or about for approximately <br /> — 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 /> Signature of Applicant o Title - <br /> Date <br /> FAICEUrRALSEWCEMLERICALIPUSSv.WKvAASTERPSIEACROACHkIEFITPMufTAPPLICAl10N00C(09113) _ <br /> 1 <br />