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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> 7—a-'C C7 kr'G ,�� t VALID ATE: <br /> (Applicant Na DRIVEWAYS: <br /> STREET <br /> AREA <br /> L l l(4 TYPE <br /> FORMS �� S.[� <br /> (Nailing Address) r r 2c - <br /> CC„ G'I 5 1( NOTES <br /> - (Cita,State,Zip Code) -- - - - <br /> Zo C) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to xcavat construct and/or-otherwise encroach on County High�wa-,�Right-of Way on <br /> the A2C� .j= side of approximately_ JQ 0 <br /> of 'Jo�_ � �tedtlmile r cS�f- <br /> by performing the following work(description of work): <br /> Work will commence on or aboutfor approximately <br /> days. <br /> i��tiy-1 - ZorS� Y <br /> 1,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 /> Signature of Applicant e Title Date <br /> M:ICEMRAaEWCESaEPICAL1PUE-W.Wt VAgSTERPS ENCROACHS1F1frPER&fTAPPIJCAnOlCOCC (09113 <br />