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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# L� � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2Q/Z` <br /> Ee-unl L er5S �� &L= VALID ,-- <br /> (Applicant Name) STREET `��—�TO C{_ S DRIVEWAYS: <br /> AREA QUAD ' _ <br /> Z3(p0 �Vr�l, � TYPE t(Mailing Address)Address) FORMS 5/�,U _R2_ <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 e excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> of �o side ofASIJ � approximately e mile <br /> zap o) , by performing the fo owing work(description of work): <br /> Work will commence on or about_M142,t�-I 7�— Nli4� ��' ��r� for approximately___ Z �3 <br /> 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 /> Signa a of Applicant-Title ��� <br /> Date <br /> I:ICENTRALSERVICEMCLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOG (09/13) <br />