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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _S-1/1, // S' OFFICE USE ONLY <br /> To: San Joaquin County [EXP. <br /> '7?j G Q 5 Z REF# <br /> Department of Public Worl<s <br /> CR# <br /> ATE ^ Tp '_��f DRIVEWAYS: <br /> (Applicant game) STREET <br /> AREA S QUAD _ <br /> TYPE <br /> (Mailing Address) FORMS l <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 7T A fn 6-E ' S k ?'G <br /> The undersigned hereby applies for permission o excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S —side of <br /> of ,, — C s S approximately 7 G tUmile_l.�cc FF <br /> by perf rming the following work(description of work): <br /> Work will commence on or about / for approximately �.,f1 <br /> 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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i e of Applicant-Title <br /> Date <br /> EI:ICEKTRALSERVICESICLERICALIPUMV$'KVAASTER.PSIENCROACHMENTPERIAITAPPLICATION.COC(09113) <br />