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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateOFFICE USE E <br /> ONLY <br /> To: San Joaquin County JOB # REF <br /> Department of Public Works APN CR # <br /> (� I_ <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ \ AREA <br /> QUAD <br /> 3L'f� IC�HI �'i'7,,LE 41 TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 'Y 7-1 - Y21 - <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the Af'CkTH side of <br /> °: s i2, <br /> approximately �Z&o feet/iTPSZC ,'_� E S! <br /> of a'L.J L)E6'y 1ejzl�)-L6 17-0 , by performing the <br /> following work (description of of work) : J),,& q`X t!' S 19e-ict i), 'T- 7'6 <br /> eX dC'SiI C C,Ai 41 -CF, ice-SroJl C <br /> /S rtP2 UYJ;)r1iLw1 �FTEIZ %c��»`K C_��?�I � r� '�Fx T- <br /> 64 <br /> ,4 P-8,4 (IL&-scL r e <br /> work will commence on or about 3 - "G' for approximately <br /> _ days . <br /> T; 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 /> Signat, .e of.- pplicant - Title Date <br /> +r _ <br />