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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date j��yl�/S OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID —j .-�G'�f0 /S <br /> DRIVEWAYS: <br /> (Applicant Name) STREET , — l; <br /> AREA <br /> /1 <br /> ` & C' jj,,\- Z/tJ TYPE - <br /> (Mailing Address) FORMS <br /> NOTES14 <br /> r <br /> (City,State,Zip Code) <br /> Ll K l 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) v�zv).QW <br /> -TC <br /> The undersigned hereby applies for permissign to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the - t— side of 0c ,lav d!` 4? LiLl C approximately -3 L i feet/mile <br /> ofby performing the following work(description of work): <br /> t <br /> Work will commence on or about 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 abovein.accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> /Signature 7 <br /> of Ap t-Title 'Date <br /> M:ICENTRALSERVICESICLERICALIPUMV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(09113) <br />