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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 75 9ZL3 REF # <br /> Department of Public Works APN CR # <br /> -7- -7-' <br /> EXP. DATE <br /> VALID br'IF-A-01 0 DRivrmys: <br /> (Applicant Name) <br /> STREET <br /> AREA -5"r4t QUAD NS <br /> TYPE 7aore no le <br /> (Mailing Address) FORMS <br /> NOTE <br /> 1 4 <br /> (City, �State, Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> .4 f-10""ee Ct j <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the <br /> side of <br /> approximately (!�§�e /mile <br /> by performing the <br /> following work (description of work) 101,lee <br /> -701 <br /> --7 <br /> Al <br /> Work will commence on or about <br /> — �c daysfor approximately <br /> 7' -he t<ndersigned certify that T am the owner of the respecti,,e prcpertv, or am <br /> 4uaiifi< d to rep-reser:- the owner and agree to do the work described above in <br /> accordance with the rules, regulaticns of San Joaquin County and subject t- <br /> inspection and approval. <br /> SigpAture of Applicant Title <br /> bate <br />