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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��T� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7�, S 2 REF# <br /> Department of Public Works APN CR# <br /> n �Il EXP.DATE f ( - 3(- 15 <br /> 1 VALID TO _a._j/-15' DRIVEWAYS: <br /> (Applicant Name) STREET } <br /> PSS- AREA <br /> y 6�o QUAD�L� <br /> TYPE 44CA <br /> (Mailing Address) FORMS <br /> ,,. //++1 0414 9 S'2 ay NOTES <br /> (City,State,Zap Code) <br /> 6—.17 G-7 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> /M -9 L4 R <br /> The un ersigned hereby applies for ppinission to excavate,construct and/or otherwise encroach on County HighwaRi <br /> the side of 5, I�ws I I cL� approximately 3 —4 Z yght-of-W on <br /> of f4 1+ AMA;,4 S�- S &mile _ <br /> -K , by performing the following work(description of work): <br /> Work will commence on or about for approximately <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 /> eKvi'. �- fit✓l1/13' <br /> e e of Applicant-Title Date <br /> M1I:ICEMRALSRVICESCLERICALIPUBSV.N'KVAASTER.PSIENCROACHFt.ENTPERPAfrAPPLICAT10ft00C(0131 <br />