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APPLICATION FOR ENCROACHMENT PERMIT <br /> IT <br /> PLEASE PRINT: <br /> Date q - / OFFICE USE ONLY <br /> / To: San Joaquin County JOB# //000s' REF# <br /> ( Department of Public Works APN /p/-/�-37 CR# <br /> EXP.DATE 14.15. <br /> �� -e c ✓t� VALID 14-4 TO fQ./5.D DRIVEWAYS: <br /> (Applicant me) STREET <br /> AREA /s�� QUAD " <br /> s � TYPE <br /> (Mailing Address) FORMS .IT <br /> NOTES <br /> r <br /> (Cfty, State,Zip Code) <br /> 1 <br /> 2-0!9' F7 -2/ 0 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies-for permisgion o excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of �� approximately /dS'o feel/ML <br /> of , by performing the following work(deem of work): <br /> /_. ____L3.n L t <br /> 2 y/ e9 ft'�ae dt e-.4 <br /> Work will commence on or about— 9P1 for approximately ! 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 /> ignature of plica -Title Date <br /> YAFORMS8 TEMPLATEWNCROACHMENL PERMIT APPUCATIONdm(MUM) <br />