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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3—2-o B OFFICE USE ONLY <br /> To. San Joaquin County JOB # /L � REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE -�-� <br /> � 1 `o ;JVALID Zs` 1)01 TO Lf-/-ca DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA1or. /cTcu^✓ QUAD <br /> TYPE <br /> (Mailing Address) FORMS tom ' <br /> NOTE <br /> (City, State, Zip Code) <br /> �rj c1 - 6"CX)o <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 side of <br /> --T�j)(Ek>') A yr-- approximately J�J fee >nile '-�,". <br /> oft ^r L; ,. 4 J by performing the <br /> following work (description of work) : ' <br /> Work will commence on or about -3 —2,57-12L? for approximately <br /> 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 tc <br /> inspection and approval. <br /> Signatur of Applicant -• Title Date <br /> MPSTEP.PS\n?,SCF.Di (5/0C) <br />