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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �,�/ f j S� OFFICE USE ONLY <br /> To: San Joaquin County JOB# , L REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID —2,1 TO DRIVEWAYS: <br /> (Applicant Name) STREET '{ <br /> , <br /> AREA .� Md v .. QUAD,�5 <br /> O�{,y We j I-A) TYPE <br /> (Mailing Address) FORMS S <br /> NOTES <br /> 14 �S 2_6 y <br /> (City,State,Zip Code) <br /> _ yu(c 3>/ -i 7(o7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> r-1/h e�*)tr� Atli <br /> S Eg H '1 S K S Tc R <br /> s" <br /> The undersigned hereby appliesgr r permission*tp excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S In side of approximately FrSZZ /mile la/asr <br /> of ,by performing the following work(description of work): <br /> 1 u /�V �,vt e�� j t�Ie 4- <br /> Work will commence on or about 7—t—t S 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 desc' bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> e of Applicant-Title Date <br /> M:ICENTRALSERNCESICLERICALIPUBSV_WKWASTERPSIEPICROACHMENT PERMIT APPLICATION.000(09113) <br />