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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , C/ S OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID �-l L 121"XTO DRIVEWAYS: <br /> (Applicant Name) STREET _ -�1r <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS ' li <br /> NOTES <br /> I <br /> (City,State,Zip Code) <br /> i 7L 1 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ?rte �.�tl•. �5c <br /> The u dersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ,(J side of_ cf ✓1�qtr 1 Uapproximately gVmile � <br /> of 4j)I'�'kl u< is 1`T S-1-i-,- by performing the following work(description of work): <br /> icy ✓�0Ic�r'e <br /> Work will commence on or about -7-1 —IS- 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 described above inacro ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i' ,S' nat e o Applicant-Title Date <br /> M.ICENTRALSERVICESICLERICALIPUBSV.WKUMSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(09113) - <br />