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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINrr <br /> Date � S D <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB 750,5-z-(.. REF # <br /> APN CR <br /> EXP. DATE <br /> VALID <br /> ?� (Applicant Name) STREET �ATO — DRIVEWAYS: <br /> AREA "k-A/ QUAD <br /> TYPEiyl/'Zc —----- <br /> (Mailing Addr <br /> ���,�'rTi►J f'+? 7.5" RMS <br /> (� (' liC'�� c�� NOTE <br /> (City, State, Zip Code) C 7.'�: 70 <br /> (Area <br /> _,.Co4a Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �'-U''E- �'0(-y ���U� <br /> �'�. mac ; : , <br /> i� <br /> The undersigned hereby applies for permissito <br /> on excavate, construct and/or <br /> p� <br /> otherwise encroach on county Highway Right-on to <br /> of F �A�� approximately yon the side of <br /> S� �00 feet/mile () I�h <br /> following work (descriptiby Performing on of work) : 5��cxT71n/ <br /> h FPerforming the <br /> Work will commence on or about <br /> s. <br /> y for <br /> da approximately <br /> I, the undersigned certify that I am the owner of the respective <br /> qualified to represent the owner and agree tProperty,do the work described above for am <br /> accordance with the rules, regulati <br /> inspection and approval. <br /> ons of San Joaquin. County and subject to <br /> '� �Ji,an�t - <br /> �Signature of Ap 'Title <br /> N' ='EF.PS\P3ESCHD:. (oj77, Date <br />