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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date _v OFFICE USE ONLY <br /> To: San Joaquin County JOB# f,/ '� REF# <br /> Department of Public Works APN CRA <br /> �''"' EXP.DATE 25 <br /> r te]. �!u�' Na�me� <br /> VALID (o•2-f•Z, TO�.CJS DRIVEWAYS: <br /> (Apph STREET _ " <br /> 2r AREAQUAD t <br /> — TYPE <br /> (Mailing ddress) FORMS <br /> NOTES _ <br /> l (Clty,State,Zip Code) <br /> 363 <br /> (Area Code•Telephone Number) <br /> Sketch Detailed plans may Pe submitted) <br /> The undersigned hereby applies for permission to ex vate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ►1G.I�l�side of �t� � Q approximately feettmile <br /> of by performing the followin work(description of workor <br /> ): <br /> f <br /> Work will commence on or about--, for approximate) days. <br /> I,the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above In accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant•Title Date <br /> rPW4VwKwnsTEc-MNcnwcHMSNTP WMIPucnnoNDN. pmj <br /> 2,8:aced 666289t,608T :0 1 •iiin » 4-'_A-11 <br />