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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 OV REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Cj–($/�(S <br /> 1iwt d�Sd-Cr ��C. VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET I/hlL�kis <br /> p L AREA ��-- QUAD <br /> TYPE <br /> (Mailing Address) FORMS 4�i_LI/W /2Zq <br /> NOTES <br /> InJ 4 e-Ztk---4, . CAS S <br /> (City,State,Yip Code) <br /> OIZ&2-- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies foLpermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the�<,n_WA, side of — . k "; approximately feet/mile <br /> of �1a 1�)Qw zL k+p--\ _, by performing the following work(description of work): <br /> -�XiS •ad 1 e�— <br /> Work will commence on or about 2 _for approximately days. <br /> I,the undersigned, certify that I am the owner of the respectiv3 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 /> �r <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALWUBBV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATIORDOC (09/13) <br />