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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -- l - D OFFICE USE ONLY <br /> To: San Joaquin County JOB# / REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE . 08 <br /> [Ltj P L l VALID 0-t S-cA TO q.1 -01B DRIVEWAYS: <br /> (Applicant Name) STREET <br /> o� <br /> _ AREA _ — QUADZ <br /> 7T-k. TYPE Ti2E <br /> (Mailing Address) FORMS , , <br /> NOTES <br /> (City,State,Zip Code) <br /> IL3- 6�o7r <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Flight-of-Way on <br /> ' the ���57" side of A«�J ,(S, approximately D IrZ�E feet/mile <br /> /i <br /> of C-©XF, AF���� � ,by performing the following work(ddescription of work): <br /> 1f l `L.l_ rJ t A �f S do lkd <br /> 1A s-C le_- <br /> W will commence on or about 4,)C-�s ( 'i� t for approximately !A re 3 . 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 /> YiW M 8 TEMPLATESENGAOACHMENT PEFUT APPUCATION.Ax(0&W <br />