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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: "� <br /> Date `- OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID I�t TO ((-/ -�¢ _ DRIVEWAYS: <br /> (Applicant Name) STREET l r 67J-0 k C_ <br /> _ AREA s���.r;f-( UAD ES <br /> �3`6✓ 5X-16A SF,, TYPE )rc <br /> (Mailing Address) FORMS S'/W/ V Z� <br /> NOTES <br /> (City,State,Zip Code) <br /> q.25) 73- 4x77 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) � ' �� !J +� <br /> IC <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_5/� side of C 1JC-eL,:)4&C- AD approximately --260 �et)mile_SW <br /> of j U) L Cz)X SToe,KTotj by performing the following work(description of work): <br /> y AQC Nbf u NfE a F" Jo,N 81,E <br /> Work will commence on or about for approximately 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 /> IF <br /> ign ture of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPUB-SV WKNASER PSLNCROACHMENT PERMIT APPLICATiCN DCC (09/13) <br />