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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 �3 `/y OFFICE USE ONLY <br /> To: San Joaquin County JOB # da REF # -- <br /> Department of Public Works APN CR # <br /> EXP. DAVE <br /> T C � VALID Z- TO t2r DRIVEDIAYS: <br /> (Applicant Name) <br /> STREET <br /> AREA 157 e.) QUAD <br /> )D T SO C77K to /• TYPE <br /> r� lz 7 FORMS � d <br /> (Mailing Add <br /> NOTE <br /> (City, state, Zip Co(f ) <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 /> gthise encroach on County Highway Right-of-Way on-the 9:,13 side.of <br /> grwe approximately 2 O feet mile r/E'C% <br /> of S WIr2 LI aec by 'performing the <br /> following work (description of work) : �GJ SSE cJf62 41NAC T EX/S TI/YC <br /> rz <br /> Work will commence on or about 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 to <br /> inspection a a roval. <br /> OZ <br /> ignature o plicant - Ti <br /> Date <br /> tle <br /> MASTER.PS\HEESCEDL (61= - - <br />