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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works <br /> APN CR# <br /> EXP. DATE <br /> VALID 0 DRIVEWAYS: <br /> (Appl!'pant Name) STREET dc-dPAX-0 ": <br /> a 9'riw <br /> -------------------------- <br /> AREA 1&0"01 QUAD <br /> "--�o),4(" IX TYPE <br /> (Mailing Address) FORMS <br /> ,5h�, e-�2, <br /> NOTES <br /> C? <br /> (City,State,Zip Code) <br /> "J 4/ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> vl' <br /> V)L f­v <br /> The undqrsigned hereby applies,for p�rmissiop,to excavate construct and/or otherwise encroach on Count p,cons ty High Right f-,V <br /> the side of, k- iay on <br /> of <br /> —approximately 200 ile__ <br /> by perfqrming the f I wing work(description <br /> f wprk): <br /> v ip ion <br /> 7 <br /> L" +1�4), 119 U 'Al <br /> Work will commence on or about <br /> for approximately.. of days. <br /> 1,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 /> Date <br /> S. <br /> OT Applicant-Title '-I <br /> - --------- <br /> E PUB-SV WKIMASTER PVE NCROACH METER M1 <br />