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APPLICATION FOR ENCROACMENT PERMIT <br /> PLEASE i?RZNT_ <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County REF <br /> Department of Public Works APN Cit # <br /> �A ( '„ EXP. DATE <br /> VALID oj Cr DRIVEWAYS: <br /> (Applicant Name) STREET <br /> a�� AR E QUAD <br /> TR <br /> (Mailing Addreea) FORMS <br /> NOTE <br /> ,.LT56c` t <br /> //�� (city, state, Zip Code) <br /> 01(�Pfq -s pQ"�(P <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plane may be submitted) <br /> o <br /> m <br /> 00 <br /> o� <br /> rn <br /> e7 = rry <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-way on the �SQVW side Pf <br /> uybv�- approximately to:3J feat/ iefi�leP'l NFiYl�1L `� <br /> by 'p4xfioming :the h} <br /> folowing work (deacrip�ion. of work. <br /> 1tvityva <br /> 4 <br /> Work will commence on or about ` for approximately <br /> 1 days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to-do the work described above in <br /> accordance with the rules, regulations of San Joaquin County And subject to <br /> inspection and approval. <br /> signature o Applica - Title Date <br /> MT.",:TR0..FB\ITRRSCHDL (6/ORI ' <br /> bo(o � fF of <br /> I Os. PRgos� Z <br /> From , <br /> Co <br /> Ph0 ��LS= <br />