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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1l��� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1.1. <br /> VALID 9`-l�'„ -oS TO l-1-©`>' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA -�!9VCA::2MI QUAD 1 , <br /> /go TYPE -'2��.4OAXI G t 96 STiC1l <br /> (Mailing Address) FORMS :!!14 _ <br /> NOTES ° <br /> (City,State,Zip Code) <br /> z'ovz� Z� �� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans maybe submitted) / jl <br /> Z9,q-,,G ;1� 44;417 1pi�tl I N r t?�7 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the A„/Ga,�' j, side of �� zp. approximately feet/mile 600 <br /> of /t, u ...,7GE AP. by performing the following work(description of work): <br /> 1 'l�5+ SsJ7"le� <br /> Work will commence on or about 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 /> Signature of Applicant-Title Date <br /> YOOFM 6TEAIPUWMENMAGMENT PERW APPUCATI0Ndoc(08108) <br />