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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 13 " 2—d 1� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73o�SZ- REF# <br /> Department of Public Works APN _ CR# <br /> _J0^ -;, I I oq 7-2 VALID <br /> ID e 5' 0 /t !,� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 5-Pc-k-16 QUAD <br /> ��� 1� TYPE 6c 06ve4te'4 <br /> (Mailing Address) FORMSSf �, <br /> NOTES <br /> (City,State,Zip Code) <br /> -7e7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encr ach on Count Highway Right-of-Way on <br /> Y 9 Y 9 Y <br /> the E side of 215' S ��- approximately 50 fe mile ai�Ti*l <br /> of--may T � , by performing the following work 0--'- <br /> *A of work): <br /> Work will commence on or about --i t for approximately An 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 /> Signature of Applicant-Title Date <br /> M.1CF.NTRALSERIACESICLERICALIPU&SVWNIM.ASTER.PSIENCROACHMENTPERMITAPPLICATION.000(09/13) <br />