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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# - 5'� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE: _fib <br /> VALID Z_ 7_I TO (� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAA f-- <br /> ?SIO—O— ���� ��W�F't� � . TYPE ��Y(� QUAD <br /> (Mailing Address) FORMS Wzyy <br /> I NOTES <br /> (City,State,Zi Code) <br /> `z 6 a 14S 2. <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 4 -ZLc' �c I✓SAL J\ �qS <br /> �J <br /> The undersig ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> thea-1-(-x side of .Qc.�r approximately . S fee it <br /> of — �-a.. _Lo r�-, ---__, by performing the following work(description of work): <br /> Work will commence on or about _11� ! 11 11(,�for approximately 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 /> Z'biged above in accor ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> na of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALWUBSVWKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />