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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date \�i � o OFFICE USE ONLY <br /> To: San Joaquin County JOB # 3j�'f'� REF # <br /> Department of Public Works APN CIT # <br /> C�1_1 FORNIR �N AT�.R S�.E�V� ��ATE - 7 <br /> TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 1550�! ��MOV 5C -W1C`o AREA fi n/ QUAD �_ + <br /> TYPE + <br /> (MailingppAddress) <br /> � FORMS <br /> C <br /> 1y a�3 NOTE T� <br /> (City, State, .Zip Code) <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 Cotnity. Highway Right-of-Way••oa-the \NF4jr . <br /> side. <br /> of - approximately feet/mile ^ <br /> by"Performing the <br /> following work (description of work) : <br /> �.�1_l.. <br /> A�'PRO>Q <br /> 3a31v IVF Q <br /> Work will commence on or about <br /> days. for approximately <br /> , <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 rulZ(� <br /> regulations 'of San Joaquin County and subject to <br /> inspection and approval to-Ia_ pg3, <br /> �•l��C'c�Pcm � O�i�"�NS �Z�k O� -O�- O� <br /> Signature of Applicant - Title Date <br /> ML9TMt.PS\MS®L (6/06{ - <br />