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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �, 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ` l REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10—3k-2-0 L <br /> CXV/ �lApplicant N ���� 1 VALID -1 r�O DRIVEWAYS: <br /> _ <br /> STREET <br /> � tAREA QUAD <br /> /` r J��� —� TYPE & Cjt <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip/Code) <br /> r <br /> (Area ode-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 4 S, <br /> The undersigned hereby applies for permission to excavat construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the LVJ,�side of 44 tenx approximately S-6'©' ee mile <br /> Of o t by performing the following work scription of work): <br /> P4"0a')^ <br /> 41 p 4 <br /> rk will commence on or a out /� for approximate y 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 /> 4 2- &0 r <br /> A'k— & <br /> Si nature of Applicant-Title ate <br /> M:ICENTMSERVICESCLERICALTWSV.WKWASTERPSENCROACMENTPERMRAPPLICATION.00('(09113) <br />