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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — f ?, — 2_®1.5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> yy <br /> EXP. DATE <br /> VALID ) 0 t DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA SjGc,�e_L QUAD 55 <br /> ® 4t TYPE tk=Lf_-- C ,Ma, p <br /> (Mailing Address) FORMS i7 <br /> NOTES <br /> CA qS � <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission toxcavate,construct and/or otherwise encroach on County HMmile <br /> Right-of-Way on <br /> the side of ( Z t l S'f approximately 1 IS�{ _ <br /> of Q e"4.l 1r-, St ,by performing the following work(description of work): <br /> Work will commence on or about Q :::2-0 p,�;—_ for approximately 6 Q 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 /> A -:!- &rz4► '-t- eaOrdoa r- 9-1-3 - z)-e) 16;- <br /> -Signature of Applicant-Title Date <br /> M:ICENTRALSERVIGESICLERICALIPU6-SV.4VKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />