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APPUCATION FOR ENCROACHMENT PERMIT <br /> PLEASE PINT: <br /> Date rit OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Departrnent of Public Works APN CR# <br /> EXP.DATE <br /> C 12 -0 T tt& i <br /> vAuD ��Wp TO n DRIVEWAYS: <br /> (Appficarit Name) STREET F"j, c-Am_p <br /> AREA MAnq_A�tQUAD <br /> -76 '3 TYPE <br /> (ftft Aftess) FORMS <br /> NOTES <br /> (City,&Nft—i�Zip Code) <br /> 6I - 146 a <br /> (Am Code-T&Omm Number) <br /> Sketch((Detailed plans my be subrnifted) P <br /> ff <br /> A-J t:y LjA)c <br /> 6�*5r <br /> '-�O;Q4L 15 OFF 12.oAQ 6Ho-�Lj,� <br /> 42 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feettmile <br /> Of by perkwrning the following work(description of work): <br /> Work will commence on or about <br /> for approximately days. <br /> 1,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 *bed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Skjnaftn of Applicart-Title <br /> NY <br /> EVUB-SVWWAV5rfRP91ENCROACHhO*TPSWAM'IrAnM=C fDl=) <br />