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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f / j ' /V_ OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?�° -� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �- <br /> VALID 0 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA _ AD <br /> 'A 6 GJ?,�`I L I"V TYPE ?t* <br /> (Mailing Address) FORMS �C I <br /> NOTES <br /> (City,State,Zip Code) <br /> - ,3/(, r/42 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -'j side of `' , , „ Z,1{ approximately �"I Smile <br /> of by performing the following work(description of work): <br /> Work will commence on or about -7-1 —1,5_ for approximately L.. C, 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 abo in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> p <br /> 11 , C� �_� `' <br /> ignatur pplicant-Title Date <br /> M:ICENTRALSERMCESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.000(0 13) <br />