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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 /> SeF%3ucp A uTo"i o Ak2-bQJz;, VALID - <br /> �� TO 4_ _ DRIVEWAYS: <br /> (Applicant Name) STREET / <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS �s /Z Z a( <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) SE A-)t A C*46\ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the G�J�, side of e-NE�2 SCA�U� approximately 20 fee ile W09744 <br /> of E �� i ffi,C.G�c� �esr C.7-0 fJ by performing the following work( escription of work): <br /> Work will commence on or about :a, for approximately f 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 /> i atu a of Applicant-Title Date <br /> cue/s T y <br /> MICENTRALSERVICESICLERICALIPU&SV WKIMASTERPSIENCRDACHMENT PERMIT APPLICATION.DOC (09/13) <br />