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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: - <br /> Date Z / OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> 4-� �UI( VALID L-Ir1— TO — ( - / (7 <br /> DRIVEWAYS: <br /> (Applicant Name) STREET Alcickyi // <br /> L � II AREA QUAD <br /> �S� ��/ ���i�► >�d . TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> r Pr 9S6n_S <br /> (City,State,Zip Code) <br /> 91(r76n - tgsz <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1 <br /> The un ersi ned hereby applies f�oC permi sion to ex avat construct and/or otherwise encroach on County Highway ht-of-Way on <br /> the a side of N. 1� t . approximately ,35 fee mil or <br /> of F, e-'a 111 er- 2a . C �� -I , by performing the following work(description of work): <br /> Work will commence on or abo a 16 — _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 /> ZworZescr&ibedabovaccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> r <br /> r P fit _ 66 2 <br /> 1 31i6 <br /> Signature of Applicant-Title Date <br /> M]CENTRALSERVICESICLERICALWUBSV.WMMASTER.PSENCROACHMENTPERMr(APPLICATION.DOC (09113) <br />