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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works �f1 S7 REF# <br /> APN — CR# <br /> �Il EXP.DATE �( _ <br /> VALID TO O-3/ DRIVEWAYS: <br /> (Applicant Name) STREET « <br /> y6go west AREA QUAD S <br /> TYPE + <br /> (Mailing Address) FORMS <br /> C414( <br /> NOTES <br /> (City,State,Yip Code) <br /> 17(Q-] <br /> (Area Code-Telephone Humber) <br /> Sketch(Detailed plans may be submitted) <br /> C 1+t—IN <br /> Z <br /> Ile-71 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> side of Aj St^cg <br /> Highway Right-of--Way on <br /> the S'I` _ A approximately (o Z.� <br /> of i- rt Mo S�isc k 40�.. 6�/mile� <br /> A ,by performing the following work(description of work): <br /> Work will commence on or about <br /> 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 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 /> ®ate <br /> "."ENTRALSERVICEStCLERICALIPUMV.Ifl'KVAASTER.PSIENCROACHf/.EHTPEFUdrrAPPLICATIOUDO0(OJ13) <br />