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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:/ <br /> Date f ,56,6 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,4g REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE &r-,00 <br /> %a h <br /> C�1 r,,r`�e 5��, ��yl VALID 9 I.� TO ,/s',08 DRIVEWAYS: <br /> 21 V <br /> (Applicant Name) STREET <br /> AREA /�� QUAD <br /> TYPE ZA;KL <br /> (Mailing Address) FORMS .; <br /> NOTES <br /> Lodi <br /> —� (City, State, Zip Code) <br /> aG g) 33.3 - 6-706 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) A (3rox,rid x local,. & a" mar ,$,r- �) wdl <br /> r <br /> f � <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-'off-Waykon <br /> the '-,s'( side of 71\0�4on k®a(� approximately rrar �feefl <br /> of Cie, Bre, lroac by performing the following work(description of work): <br /> Tvb1r 0,01 r r" a L.Q A G c I 0 u e L /1 ItAtNj LOW j r <br /> Workwill commence on or about "'` for approximately 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 /> Signature of Applicant-Title Date <br /> EAPUB-SV.WNIMASTER.PMENCROACHMENT PERMIT APPLICATION.DOC (010) <br />