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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT//:__ <br /> Date CJ� S OFFICE USE ONLY <br /> To: San Joaquin County JOB# �lad01�- - REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ �-/$ -lS <br /> s o 1 c�� �I s r -Y VALID 15-,l TO J� J$ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> � AREA <br /> 53 U I�I�I�S� TYPE 1 ��f�UA <br /> `T <br /> (Mailing Address) FORMS 1&141 <br /> C l UL�l2- I✓l �l CQ 9 NOTES <br /> (City,State,Zip Code) <br /> 9 Z J) 7�3-- Li V-7 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted)b7mitted) <br /> A1 � 14 ('t46b <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Waw on <br /> the 5Ck4T 0 side of_�E6 D9., approximately 0 fee ileO 1 N <br /> of [.�d Ivy 2 �� aT� KTc�+y by performing the following work( escription of work): <br /> Work will commence on or about 7-- i 1 :5 _for approximately '3 e} 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 escribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> S nature of Applicant-Title Date <br /> MICENTRALSERVICESCLERICALIPU&SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (03113 <br />