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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 13 — OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> p� EXP.DATE it / , <br /> VALID �a <br /> -7 If TOy` 1� r � ' DRIVEWAYS: <br /> (Applicant Name) STREET gf r <br /> AREA ,r - s�t QUAD <br /> 41 � �� TYPE C , c A,"c+�c <br /> (Mailing Address) FORMS S 'r, TeAe'4 It, <br /> NOTES <br /> (City,State, Zip Code) <br /> -7 '7 <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 encroach on County Highway Right-of-Way on <br /> the .S side of 2,o-31 AE 7f h -4`� approximately, e ile <br /> of 71�- by performing the following workescription of work): <br /> Work will commence on or about Q!g-- for approximately -�,n days. <br /> I, the undersigned, certify that I am the owner of the respective properly,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 /> —4- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.00C (091M) <br />