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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7121 I L S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2__ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> � _1 ,-a fu t� r Q G L VALID TO ��- DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 1A UD IV <br /> n JD s (I TYPE <br /> (Mailing Address) FORMS � 1,j <br /> NOTES <br /> Sa c�.L,.t.�t-in r C'Ar `jSGOS <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> c' <br /> The undersigned hereby applies for permissi n to excavate,construct and/or otherwise encroach on County HigPee <br /> Right-of-Way on <br /> the ou-Y side of Cka �'�� � approximately mile e�S <br /> of ']',',nG a C-e Sia�Ic. �,n by performing the following work ription of work): <br /> a c4 o over .Qe-dr- <br /> Work will commence on or about ZtI 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 /> '),z,�"A- <br /> P(, � 7 ZII, ar- � s <br /> Signature of Applicant-Title Date <br /> S Q•GC <br /> M ICENTRALSERVICESICLERICALWUBSV.WNIMASTER P51ENCROACHMENT PERMIT APPLICATION DOC (09113) <br />