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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �'2 S�2 C I OFFICE USE ONLY <br /> To: San Joaquin County JOB# t '�( `c� REF# <br /> Department of Public Works APN CR# <br /> ,*^ EXP.DATE <br /> L C r2;ti�L VALID 'f0 > DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD i <br /> t TYPE <br /> (Mailing Address) FORMS <br /> r�f� NOTES <br /> kv I (City, State,Zip Code) <br /> -? - 1� V(- _fGGE <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> G� <br /> ef A f-'o,G tr AL1 t c t.� l s� <br /> The undersi ned hg eby applies for permission to excavate,construct and/or otherwise encroach on County High w Right-of- ay on <br /> the 1v rn side of �W� y1-�t, T approximately S�1 j ee ile 'Z') �u�'_�{, <br /> of by performing the following work(description of work): <br /> Work will commence on or about 1 for approximately D - days. <br /> 1 <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 Applicant-Title Date <br /> EAPUB-SV.WMMASTER.PSIE NCROACHMENT PERMIT APPLICATION.DOC (0908) <br />