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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C.a. �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# jQ REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATET $ �j 57 <br /> VALID t�1 �1i 0 8 ZI I5 DRIVEWAYS: <br /> (Applicant Name) STREET -$(- ;r -Dje,✓E <br /> AREA SroeAcmnf QUAD I-V <br /> l h IJiC { C ��'{ i.' _ TYPE MP, RoAt> C4.4sy" <br /> (Mailing Address) FORMS <br /> `._ NOTES <br /> (City, State,Zip Code) a& zCy <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> .wALA <br /> 1 4 9 <br /> —CIA ew <br /> Ae <br /> n, <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Side-Of 1 -� 1 t` ' _approximately feeyfnife <br /> of rft�t'3�' (:4111)__ by performing the following work(description of work): <br /> c fUF <br /> i < <br /> Work will commence on or about N. 4-4=t— 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 in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title bate <br /> E'PUB.SV.WK1hIASTERPSIENCROACHMENT PERMIT APPLICATION,DOC (OV08) <br />