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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# F#RE <br /> Z40-0057 Department of Public Works APN RE#EXP.DATE— cA VALID /,S�l,8 <br /> (Applicant Name) STREET TO ��3,0$ DRIVEWAYS: <br /> TYPEAREA QUAD t%(Mailing Address) <br /> l 5D FORMS <br /> NOTES <br /> g5Y3 3- <br /> (City,State,Zip Code) -- <br /> g�� <br /> &7q 2-aoo - <br /> (Area Code-Telephone Number) — <br /> Sketch(Detailed plans may be submitted) <br /> Va <br /> f � <br /> L'yo WA <br /> The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwway Right-of-Way on <br /> (4+ the d o sic"f VA(I{)p� Coyr,�— approximately. 4/25 7zmile 0 <br /> performing the following work(description of <br /> Work will commence-on <br /> —T ---— _ for approximately S 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 <br /> / ate <br /> E.IPUB-SVWKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) J <br /> (�✓r <br /> `f <br />