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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /� S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 2 00 S Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 16-1-d' <br /> VALIDTO - DRIVEWAYS: <br /> (Applicant Name) STREET ! li <br /> / AREA '�( QUAD <br /> VV _ <br /> eS f L/U TYPE <br /> (Mailing Address) FORMS <br /> 4-L• gs-z-bI / NOTES <br /> (City,State,Zip Code) <br /> �)l6-1 7(� -? <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S � 14T" ifs s�fTW <br /> (dq <br /> The u ersigned hereby applie for permission to excavate,construct and/or otherwise encroach on County Highway Right-of- ay on <br /> the side of 4 14-U.? approximately 23 - �et�mile <br /> of +�� -v by performing the following work(description of work): <br /> a <br /> Work will commence on or about - for approximately f d t� days. <br /> I,the undersigned,certi I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described ve in ordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> w I <br /> e �di ►�<<t�.v � �S Ifs <br /> Signature of Applicant-Title Date <br /> M:ICENRRALSERVICESICLERICALIPUMV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.000 (09/13) <br />