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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S Z q {,j OFFICE USE ONLY <br /> To: San Joaquin County JOB# //dbaS REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2. (. 17 <br /> atc, 4, � 00 VALID TO Z,{.I ( DRIVEWAYS: <br /> (Applicant Name) STREET S 4OR31 <br /> AREA 5mek,7b,✓ QUAD CC <br /> �' ►Q� TYPE u -Ics E <br /> (Mailing Address) FORMS ss 1yo�, -Z j <br /> NOTES <br /> (City,State,Zip Code) <br /> Z.oq-, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> t ox <br /> y x `1 <br /> �det ''N Y r4fi Sewer nn41 N CW Cfw St,we� � - <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the�m &L side of ©X�ee.c �,�p� approximately S 061 feet/mile CZ rJt <br /> of �v, , by performing the following work(description of work): <br /> Work will commence on or about 1- 10 t\ for approximately 2d 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 /> rgnature Applicant-Tie- Date <br /> EiPUBS/.WKVAASTERPSIENCROACHEIENTPERMITAPPUCATION.DOC (01108) <br />