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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: I <br /> Date 2-_ 1 -7- i OFFICE USE ONLY <br /> To: San Joaquin County JOB# 100 7r REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE r7' -t,5,t l <br /> S&P�(�O /-(>;A,,✓ 1JA 11'x!�JL/A t!- VALID 4--1 j-l5 TO -15 DRIVEWAYS: <br /> (Applicant Name) STREET ,k1P <br /> AREA QUAD <br /> TYPE Br <br /> (Mailing Address) FORMS !,S Wm P,2--R <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) �',�( b <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High. Right-of-Way on <br /> the SLA i H sideof r���i r_»u� XhJ approximately i I <� CfeedV ile 64,5i <br /> of CNA LAG' C;I Tl. ,CC. V _, by performing the following work(description of work): <br /> 1�)�I 4 C(- I r �� '' (;(��.�.�(d 1T �U iC �. _f►i Ski='l/�'�� <br /> Work will commence on or about I— 1 ci _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 /> - / 7 / � <br /> ligfiiiifuie of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPUB-SV WKIMASTERPSENCROACHMENT PERMIT APPLICATION DOC (09113) <br />