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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dated ,l� ) OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DVALID ATE \'Z•t3•e��'i <br /> 1 M•n9 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 1-o QUAD <br /> TYPE <br /> ` <br /> (Mailing Address) FORMS ��14ml,�- <br /> NOTES <br /> (City. State. Zip Code) <br /> gZ-5-4111- :5-? L-i <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) jf <br /> l <br /> The undersigned hereby applies for permission toxcavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ea:; &'E`5:'- side of t <br /> �L'��-� �.� approximately (via FT feet/mile <br /> of (( h f�,yyam by performing the following work(description of work): <br /> �i+"Lota't �M�t f`CL3Ce s ! ' Lj 1 (0eA 4er"" l✓eA�o } jI <br /> IJ <br /> Work will commence on or about 9/1-Loi 9/1-Lofor approximately 00 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 Applicant-Title`J Date <br /> Y FORMS S TEMPLATESENCROACHb1ENT PERMIT APPLICATIGN.dcc I08'08) <br />