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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J 7.-3 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE 2 !!o <br /> VALID 14 114. TO 2/1//4 DRIVEWAYS: <br /> (Applicant Name) STA. <br /> AREA QUAD NAI <br /> TYPE4 <br /> "' tG <!!�WT a. �E►�1 <br /> (Mailing Address) FORMS <br /> -, NOTES � <br /> �— (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, cgg��s��truct and/or otherwise encroach on County High Pee <br /> Right-of-W y on <br /> the `�Cu6.4 �-, side of �- Far G S�- L.a V—e �C.ca_ approximately—4k leof N< G �,�r - v.•,c,`$-zy �,., o b erformin the followin work ri iY P 9 9 ( pt on of work): <br /> -TY cin S Gwk' , /"' rP j? a C e <br /> Work will commence on or about t 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/2 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALWUBSV.WKIP,(ASTER.PSIENCROACHMENFPERMFr APPLICATION.DOC (09/13) <br />