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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# /f REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE .,0 <br /> 95 <br /> &r18L1"C4'7 0nC .t VALID TO JD. <br /> DRIVEWAYS: <br /> (Applicant Namqf STREET �iA <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS , <br /> �./ �5�6y� NOTES <br /> (City,State,Zip Code)��,e 4 } <br /> 777- `l-7`Y q --/b7 Llyq ot�r <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 4ir LJ <br /> 8,0, <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the C.�/�'-S side of -1 - 1. ar a approximately ee mile r f- <br /> of t n6 L4':��a , by performing the following work(description of work): <br /> it tC. e -41. w.l 9-t, 02.;g a f.ke , fe,U;,fe i2,'/u : �+-►a <br /> Work will commence on or about for approximately 7 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 /> ig ature of Applicant-Title Date <br /> Y\FORMS d TEMPUITES�ENCROACHMENT PERMIT APPUCATION.doc 108408j <br />