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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (O ' ��� / OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73x07 I -3 REF # <br /> Department of Public Works APN CR # <br /> 1EXP. DATE -/,s <br /> 7 VALID TO q-[Lo. DRIVEWAYS: <br /> / (Applicant Name) STREET \/ <br /> AREA Z QUAD <br /> TYPE Q hCti <br /> (Mailing Address) J/ FORMS <br /> �G� N ��p�a NOTE <br /> (City, State, Zi Code) <br /> L <br /> (Area Code - Telephone Number) <br /> zi <br /> Sketch (Detailed plans may be submitted) <br /> Ta 6 <br /> The undersigned hereby applies for permission to excavate, cc struct and/or <br /> otherwise encroach on County Highway Right-of-Way on them side o <br /> �Q approximately _ Q ee /mile /vd� <br /> of by .perforining the <br /> following ork (description of work)/,: i 1 t' Ne <br /> u I i 4;,1/� o d� 7 <br /> ear hey �� <br /> Work will commence on or about -1� for approximately <br /> - (1 G 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 and approval. <br /> ignature of Ap cant - T tle Date <br /> MAS-79A.PS'FEES=L (6,'C 0) <br />