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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -9 — 2 C l- OFFICE USE ONLY <br /> To: San Joaquin County JOB# �g�o��_� REF# <br /> Department of Public Works APN CR# <br /> /�pp ® EXP.DATE <br /> I"K3 T m 3! 1 6 VALID TO rr j t'" DRIVEWAYS: <br /> (Applicant Name) STREET <br /> tUeAREA ack�o�► QUAD — <br /> �! q0 �� La he TYPE !/ ,e vY� ;✓ <br /> (Mailing Address) FORMSrr'7 <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 excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of 2 l S e e r t r u co approximately N t,"O .fce mile S <br /> of !� A 9 4,S l�t'Mtrftid(A ��®���-�� by performing e-following ff llowing work(—escription of work): <br /> Work will commence on or about ) a- zze'Lg-- for approximately 9 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 /> P ryA r 9--1.3 - --1z''!:) G - <br /> Signature of Applicant-Title Date <br /> M.ICENTRALSERMCESICLERICALIPUB-SV.WKW.ASIER.PSIENCROACHMENT PERMIT APPLICATION.COC(09113) <br />