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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of/Public;Works' APN _ CR# <br /> ALIDP.DATE )l� TO <br /> (ApplicantName) STREET 0 DRIVEWAYS: <br /> / A t A �r� <br /> �`� �G/ .� // REA QUAD <br /> azo �o�e.� 7�s TYPE hea Y <br /> (Mailing Address) FORMS �- <br /> /y NOTES <br /> (City,State,Zip Code) -- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> /\/ <br /> !7� ��'"/�✓Q'-�� f.fit /�lO�,r�,�Jcs Di /!?'>.rJ�� ��/ ���J fy G..� <br /> i <br /> The undersigned hereby applies f r permission to�c--� <br /> -caet and/or otherwise encroach on County Highway Right-of-Way on <br /> the 5-,-/ side of approximately %UO G.. feetlmife <br /> of by pe orming the following work(description of wo ): <br /> L <br /> ------------------------- <br /> Work will commence on or about /d Cl .5 or approximately l 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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i <br /> Signature of A Title <br /> Date <br /> E:M-6V.WKWA rOU'McROACK*rrraWAFIP-=nOKC"(ame) <br /> i <br /> i <br />