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1 _ <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date V 1//(,-,,// —)*— OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE I-I— / <br /> VALID 0 t 20Z-,L DRIVEWAYS: <br /> (Applicant Name) STREET Lr��;�S'�-� <br /> j� / AREA c�G +,/�QUAD <br /> W �i- / ",I) TYPE <br /> (Mailing Address) FORMS SS <br /> `'� < k+z►� NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> the u dersigned hereby applies fpr permission to excavate,construct and/or otherwise encroach on County Highway Right-of yUay on <br /> side of_ l lJ=� } 4 S approximately �_ <br /> of L i Ji ,� ! j�U� ee mile 1 <br /> Z," c by performing the following work(description of work): <br /> Work will commence on or about_ co), for approximately <br /> 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 describe ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> igna pplicant-Title <br /> Date <br /> M:ICENTRAL'ERVICES'CLERICALIPUBSV.WKWnTER.PSe4CROACHMENTPERMRAPPUCATION.00C(09113) <br />