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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> 3 <br /> � � OFFICE USE ONLY <br /> To: San Joaquin County JOB# G; REF# <br /> Department of Public Works APN CR# <br /> -�-- EXP. DATE <br /> �CR�M1I a01� _ VALID �f l�-TO L —� "Z�f DRIVEWAYS: <br /> (Applicant Name) STREET <br /> I�K <br /> AREA ''�1r CQUAD <br /> 3� 13 ( _ <br /> � � ���4IIE'N �D TYPElug ltr <br /> (Mailing Address) FORMS <br /> NOTES <br /> _'f 1 i ice_ �ar Cly- 6�jjCz`'r <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the P_q-Sside of 13V approximately a fe <br /> of 1,.�. �� �J i 1�1�' � � ile.� <br /> f ,�11�� , by performing the following work(description of work): <br /> OrrAl-A A- <br /> tiL _ <br /> Work will commence on or about — o for approximately�, — � 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 /> Sign re pplicant-Title �Ir�' <br /> Date <br /> M:ICEITfRALSERVICESICLERICALIPUB-SVWKIMASTER,PSIENCROACHMENT PERMIT APPLICATION DOC (09/13) <br />