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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /Ct h OFFICE USE ONLY <br /> To: San Joaquin County JOB# ? 6 — REF# <br /> Department of Public Works APN CR_# <br /> EXP.DATE <br /> VALID —1�� TO DRIVEWAYS: <br /> (Applicant Name) STREET Ae Av <br /> AREA UAD <br /> Z-1 CtJ + L<A) TYPE ✓ <br /> (Mailing Address) FORMS I <br /> NOTES <br /> S 2--c-4 <br /> (City,State,Zip Code) <br /> �/v /L-- ( 7C,I <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) � t « �C��_, <br /> �1 �I - ��, <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the .'c, S1— sideof C�zv+v,;dR approximately 3 famile So, <br /> Of C4 �T La,,St s-,lu,-kms, 3fzlcl, by performing the following work(description of work): <br /> t�> f��3ti�✓ I�Jc,J; ��f ivy St✓mak <br /> Work will commence on or about --7--1-11-1 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 describ-a ve'm' ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i <br /> ��`� <br /> �Sign� AJ-Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUBSV.WKNMSTER-PSIENCROACHAIENT PERMIT APPLICATIONDOC (09113) <br />