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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �,%_ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE C.. 3 E-. C !? <br /> VALID TO DRIVEWAYS. <br /> (Applicant Name) STREET <br /> IJ' AREA �' x'; c QUAD '/ ` <br /> '�S Iv } �,-i't- TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City:SState,Zip Code) <br /> t2_ - <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> AAA�&� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise ewroach on County Highw4 Right-of-Way on <br /> the a side of�aw _ fk}_o _T approximately(V_3 q 0 ° fe 'Nile S <br /> of Arad Am <<0 y performing the following work(description of work): <br /> Work will commence on or about - —O for approximately_50 y <br /> da s. <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 Applican -Title <br /> Phi'4A Date <br /> ale <br /> e PUB S'/Wn1MAS! rR P�ENCP_r)ACI:VP![PEEN',APR CAI i"I roc. (O'!8! <br /> ( 4AAr <br />