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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date \�! " -72-00 . <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# (1000_ REF# <br /> Department of Public Works APN CR# <br /> i�C7K E �j p(1,►�S cs� -.fir- EXP.DATE i G-f, 2 oc,� <br /> VALID TO J Z_, _�cz'r.t DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAAPUAD <br /> TYPE " w <br /> (Mailing Address) FORMS - (ti Lk) _ <br /> NOTES <br /> old i o , CIO . �S�( — <br /> (City,State,Zip Code) <br /> C2©43 -44Llq Zero <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> 41�e sk*of <br /> of 1 Z feed Sc�. .. <br /> --I-- by performing the following work(description of work): <br /> R sC�i .\.a L (3Drvt, <br /> L" <br /> Work will commence on or aboutfor approximately_ Z. 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 desc ' above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> b mevq /7 /0� <br /> fl�Signature of Applicant-Title Date <br /> E IPU"V.WKIMASTER.SIENCROACRMENT PERMIT APPLICATION.DOC (01/18) <br />