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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -;� 2 e l!� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> j� EXP.DATE <br /> .3 VALID /���i - TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA c 4- QUAD <br /> E ��® �"a A,® TYPE ee%le Le <br /> (Mailing Address) FORMS ! <br /> NOTES <br /> '/ <br /> (City,State, Zip Code) <br /> �lD le;.-® 1 ' 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 C side of 3 q q -4 5,"A e-1 et 'p approximately -712,(_ g w /erk(deQmile S <br /> of t t! a.5 L'r , -t-"n 7�o -r,.>A2, by performing the followinoscription of work): <br /> Work will commence on or about __ �b rev for approximately. I 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:ICENTRALSERVICESICLERICALIPUR-SV.WKI%MTER.PSIENCROACHMENTPERMITAPPLICATIONDOC(09113) <br />