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APPLICATION FOR ENCROACHMENT ERMIT <br /> PLEASE PRINT: <br /> Date - ( O OFFICE USE ONLY <br /> To: San Joaquin County JOB# L 4REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> -T�rJCohn S ��kC���� � S: <br /> l idh M A y D VALID - t v TO I c�YS'-oDRIVEWAY <br /> ff <br /> (Applicant Name) STREET <br /> �^ AREA S-Vo AD <br /> /t( <br /> 7 3 1 a `� S4 QUTA TYPE 'Si <br /> (Mailing Address) FORMS <br /> 'SAC 6'0�) C lq_ S Z l J, NOTES <br /> (City, Sate,Zip Code) <br /> ? 0q- q c '- (—e z ( y <br /> (Area Code-Telephone Number) <br /> A <br /> Sketch(Detailed plans may be submitted) <br /> '+,foe-. 4- S� �� A"Z �� ' (C A '4o i G e4 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way ori �/ <br /> the k 4 K side of q S , �++t S e &4 approximate) V-z �'-1-e feettmile Na $-F� <br /> of � G rt < by performing the following w9rk(description of work): <br /> Work will commence on or about 7 r 09 for approximately - w 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 Apptica -Title Date <br /> Y\FORMS d TEMPLATESR4ROACHMENT PERM T APPUCAT04.dw LGM) <br />