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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '2—Z-O ISS OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO S / S' DRIVEWAYS: <br /> (Applicant Name) STREET /1 k <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS SS IAS la �Z� <br /> NOTES <br /> k% r CA- q �0 <br /> (City, State,Zip Code) <br /> cicl - <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 Highway Right-of-Way on <br /> the! 101 side of '7P to % approximately feet/mile <br /> of 133 -/ h±Ph &C-'c , by performing the following work(description of work): <br /> p�2, ��f�i) '�' <br /> 44V CPC B4 h�ilf�ai f�VA O?iIr a0 + <br /> Work will commence on or about for approximately L>C 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 /> —Z-2101S <br /> Signature of Appl ant-Title Date <br /> MICENTRALSERVICE5ICLERICALIPUB-SV WKIMASTER.P5IENCROACHMENT PERMIT APPLICATION DOC (09/13) <br />