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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ gA i/h OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3V�S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ 1,_15 <br /> CA c eJV►'L- VALID C,—V)-(S TO / DRIVEWAYS: <br /> (Applicant Name) STREET 5^� <br /> ' ` / I f' QUAD <br /> t'I p L4 U W,P.—s ! /�(/ TYPE ►-1 <br /> (Mailing Address) FORMS Z <br /> NOTES <br /> 0A '?Q ay <br /> (City,State,Zip Code) <br /> 31b—r7�� <br /> (Area 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 Highway Right-of-Way on <br /> the- <br /> Ovt-^ side of t-o We,; -,A IA u..Q approximately q bU de'�mile�� <br /> Of a I-i1 u , by performing the following work(description of work): <br /> Zl v% e o. <br /> Zo\ L <br /> Work will commence on or about I0-L S" for approximately "5o days. <br /> I, the undersigned,cern a the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described a in acco nce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> e � <br /> ignature of Applicant-Title Date <br /> M:ICENTRALSERVICESCLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(09113) <br />