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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date "t//G,I/f. <br />To:San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />4(j.4o WtJ+LtU <br />(Mailing Address) <br />.~Q..l-+qSLAV <br />(City,State,Zip Code) <br />'IOIt'-y-","./7(.7 <br />(Area Code.Telephone Number) <br />OFFICE USE ONLY <br />JOB#7"700<;2-REF# <br />APN CR#EXP.DATE 6-/$-16VALID"3-f(-lb TO 6 -/5-/6 DRIVEWAYS:STREET ~vron • <br />AREA if;;;;'y QUAD 5147 • <br />TYPE ~Uho/e • <br />FORMS f1tVVR.2?NOTES <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,cons(ruct and/or otherwise encroach on County Highway Right-of-Way on <br />the 11"*..side of &1\(p...(J approximately <io S"V <!!litimile'SMM.. <br />of li...,,.Ytf¥"by erforming the following work (description of work): <br />-e""",t;..j <br />Work will commence on or about Ol.~for approximately days. <br />CfliIraI/bDate <br />,...,.<ture of Applicant.Title <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 describe ve i ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />E1PlJB.SV.WI(\M!\STERPSlENCROACHMENT PERMfT AJ'PlICATlON.DOC {01IOB)