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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7- 15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110 05 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> yAV`z- X)C A C VALID 3- (S TO DRIVEWAYS: <br /> (Applicant Name) STREET e <br /> AREA iA QUAD <br /> TYPE o P <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 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 Higher Right-of-Way on <br /> the v/� sideof ST*��r,-" ST, approximately 150- fCeetl�nile No��-I <br /> of �7 T U Sti , eXtE ICAJ �,�1: ?_, by performing the following work(description of work): <br /> ,rrP� �F-IZ6,%A ._PO�C 7:.;, _l lee <br /> Work will commence on or about 3-- 3- 15 _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 de 'bed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> J1�T C�3�,f�ieV �Iv — <br /> -27- 15 <br /> ig of Applicant-Title Date <br /> MIC.TPAl.I.CESICLEPICIIIII&SV WNIMASTER.PS CROACHMENT PERMIT APPLICATION.DOC (09113) <br />