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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date "t//(,.//G. <br />To:San Joaquin County <br />Department of Public Works <br />(G-f! <br />(Applicant Name) <br />4r:J-1IJ WtJi:LJU <br />(Mailing Address) <br />~\Y'"Q.~'lJLc8 <br />(City,State.Zip Code) <br />'10lr -Yr..~17(.7 <br />(Area Code -Telephone Number) <br />OFFiCE USE ONLY <br />JOB#7300>2-REF# <br />APN CR# <br />EXP.DATE 6-l>-{6 <br />VALID JeC-lh TO 6-/>-/6 DRIVEWAYS:.STREET gy;on • <br />AREA QUAD ~W'• <br />TYPE J~~•'Ih IeFORMSS~WW lb."!NOTES <br />Sketch (Detailed plans may be submitted) <br />,, <br />The undersigned hereby appiie for permissi09 to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the tJn.+-side of f\approximately I 30 4 u ~mile S.tAt--. <br />of ~:••<.,,by performing the following work (description of work):.::>v.-\z!I .'" <br />Work will commence on or about OL .~for approximateiy days. <br />CfL/IroI!bDate <br />/..( <br />ture of Applicant.Title <br />I,the undersigned,certify that I am the owner of the respective property,or am quaiified to represent the owner and agree to do the <br />work describe ve i ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />E:'J'UEl-SV.WKlMASTERPSlEtlCROAOiMENT PERm APPllCATlON.DOC {OlIO!}