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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (011 CO OFFICE USE ONLY <br /> To: San Joaquin County JOB# _11A_90!';_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE —��1S�•a� <br /> �PtGt1 LOtsStY2ctc*t! VALID 1 TO 11•tS:tSrt' _ DRIVEWAYS: <br /> (Applicant Name) STREET 4P s n-►SBt444 <br /> AREA Sra4�ii✓ QUAD k <br /> 3031 W jAAWcL -_Q- *flo TYPE AT>A EAMP <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> 74- 05.22 <br /> JOc <br /> (Area Co e.Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies forppermission to excavate,construct and/or otherwise encroach on County High , Right-of-Way on <br /> the �'r' side of C-��H-.�.-NS-0—e approximately ISO <br /> fee' t�Dnile <br /> of ``zaft-0 , by performing the following work(description of work): <br /> • t ;,,,, a �•K l . -J) <br /> ADN e"Orm-a <br /> Work will commence on or about for approximately days. <br /> I, the undersigned,certify that l 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 /> ::�� � ' Sf P 1 t1 O1 <br /> Signa ure of Applicant-Tale <br /> Date <br /> Y';OPMS 8 TEMPLATESIUVIDACHMENT PERAT APPUCATiON.=IOM08) <br />