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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / .3 " 2-®��� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73wC2-4, REF# <br /> Department of Public Works APN CR# <br /> �5 pm _311 <br /> 11 q ?'7 16 <br /> .Z VAL.DDATE [ 1 l <br /> i(0 S 0 )t 15 DRIVEWAYS: <br /> (Applicant Name!) STREET a�sorR x <br /> AREA 6f QUAD L=5 <br /> Iq �l0 TYPE '1�e1� ccpaoem Qc if) <br /> (Mailing Address) FORMS wx7� Z Tre► A Ci11 <br /> tYn9 �vllcsr <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 excav te,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the r side of� IV WI t nG4-4or approximately— e mile_ 5 __ <br /> of I=ce-VA6 *_ __ _ �®c 71>- by performing the following workescription of work): <br /> Work will commence on or about �- �p� for approximately 'n —days. <br /> s. <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 /> CiAj <br /> Signature of Applicant-Title ®ate <br /> MaCENTRALSERMCESICLERICALIPUMV.WKUAJISTER.PSIENCROACHMENT PERMIT APPLICATIORDO'c(09/13) <br />