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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date i OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7_2,W5?_—It REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE <br /> VALIDva <br /> TO tp 1S'!i DRIVEWAYS: <br /> (Applicant Name) STREETAREAQUAD NES <br /> TYPE F'!G e�'ES <br /> (Mailing Address) FORMS W <br /> � C� NOTES <br /> (City,State,Zip Code) <br /> (Area Cade•fielephane Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permiss' n to excavate,construct and/or otherwise encroach on County Nigh a Right-of--Way on <br /> the 5, f-. side of (3 ( approximately t;� o 0 fee mile LX'S� <br /> of / {' f ` - by performing the following work ascription of work): <br /> p <br /> Work will commence on or about for approximatelydays. <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 /> Signature of Applic t-= itle•... <br /> A�ate <br /> Et Ug-SV.YMl1ASTER PSENCRaACH1.EttTPp21.�MPtICAT10II COC(01w) <br />