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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# //apps REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE /013/Dg <br /> VALIDp TO O/q DRIVEWAYS: <br /> (Applicant Name) STREET --�� — <br /> AREA QUAD <br /> rD, IF701 lG 1 IYPE 4i5'--%a 7e. <br /> (MailingAddress) FORMS /��w <br /> NOTES <br /> (City, State, Zip Code) <br /> -- <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> C ✓�5� 7� Adneo�� T� �errlc'-A ire 17.���1:�•t 5 � -i�^< P�ve�r• <br /> �.� ��;5�.� �-,c crlos�•,� -��,- -rte, �q�� -r,> ,x r��� Ali <br /> n. 'T� � cv r�..t <br /> -r0 LJ�/ to ��ccc 41 V.A1y g,>Ljer15si<-Ic�ne� <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighPescription <br /> Right-of-Way on <br /> the 0u side of�( ( �-1-�r/� � approximately 50 mile <br /> of (}' I M—"(IJ by performing the following work of work): <br /> Ale- <br /> Work will commence on or about '71 ( � Gtr for approximately 2( 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 /> CIL, <br /> Sire of Applicant-Title l Date <br /> YtTORMS 6 TEMPLATET <br /> CHMENT PERMIT APPUCATIONAX(08/081 <br />