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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �,2� JlOFFICE USE ONLY <br /> To: San Joaquin County JOB# ,'�-7 REF.# <br /> Department of Public Works APN CR# <br /> EXP.DATE w. _ G/ - <br /> 0A i A VV �TEP.. �C121 III VALID 3 "ZS 2G 0 DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> 1(0 F AREA St�C i �� QUAD `±�S <br /> Y S� TYPE t <br /> (Mailing Address) - i <br /> FORMS � <br /> �/%,�1�;_ �� Tr�.�_ c11� <br /> --,ST-C)L Y-71 © NI � `n7 15�J NOTES <br /> (City,State,Zip Code) <br /> 1, V -- <br /> (Area Code a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Higljede <br /> Right-of-Way on <br /> the rt side of _ c�Tnc� -C\1 <br /> of i approximately ,�,�O mile c -t <br /> by performing the following work(description of work): <br /> X Ll <br /> Work will commence on or about Iifor approximately days. <br /> y <br /> I,the undersigned,certify that I am the owner of the respective prop rty,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 /> �� } yLALSignature of Applicant e Title <br /> Date <br /> M'."EWRA(SBUCMCLEPJCAUPU&SVWKV✓kSTEPnMT'CROACH%IETJTPEmirrp,oPUCAnOaDDC(09,13) <br /> 1 <br />