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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date a (2 (f//� OFFICE USE ONLY <br /> To: San Joaquin County JOB# (,►(,� 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO <br /> (Applicant Name) STREET DRIVEWAYS: <br /> AREAQUAD <br /> r,Z760 �/ <br /> 1 � ��/ / � TYPE <br /> (Mailing Address) FORMS <br /> / , � S— <br /> Jv NOTES <br /> (CitY,,/State,Zip Code) <br /> V-7 y. y 3 6 C/ �,��M 52���e ccl�) <br /> (Area Code-TelephoneNumber <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way <br /> the I>)"i-1I side of � /7�ir/dL J% <br /> of d�' j,���,!�/� approximately %lJ U feet/mile / � <br /> �`'` ��'U '�-f� a by performing the following work(description of work): <br /> v <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 descri ed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />