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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 26 OFFICE USE ONLY <br /> To: San Joaquin County JOB# _6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> G — VALID 1(,)-4,?e-,/<TO /--���� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ® AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> gg q� NOTES <br /> qS 2-oq <br /> (City,State,Zip Code) <br /> I-Vi Z/C,--17 & -7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies fo permissio to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the KGs side of iC 0 approximately Z q 'S t feeYmie <br /> of K e++t e LId o d; by performing t e following work description of work): <br /> ' < Vt 12 r..c 4 w�' t, L <br /> Work will commence on or aboutt>e, for approximately days. <br /> 1,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 descnxwobove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si Applicant-Title Date <br /> M:(CENTRALSERMCESICLERICALIPUB.SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC(09113) <br />