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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date " 7- OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> W EXP. DATE 2--i <br /> G NAL l j /�L / �y �� � VALID 1,�-21 - TO l- r1.�j� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ AREA CI N- QUAD ' <br /> Bel SA �% TYPE <br /> (Mailing Address) FORMS 2 <br /> NOTES <br /> (City, State,Zip Code) <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 High _et/Right-of-Way on <br /> the NGS i-i side of� a r �� � - approximately 7-/ feile W e6 <br /> of ��- DGW--R DO5 i= Si'�c k�c�N by performing the following work scription of work): <br /> _,�,/'� �`"li'r�%►� SDiN� /�c7�E T6 �r��1�':"1 1z�- �1.��".G'! L /� <br /> Work will commence on or about !a-- 2- for approximately :30 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 /> Si nature of Applicant-TtleDate <br /> MICE:NTRFLSERVICES'CLERICALIPU9-SV WRIMASTER PSIENCROACHMENT PERMIT APPLCATION OOC09113 <br /> I 1 <br />