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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -49 OFFICE USE WY <br /> To: San Joaqdn County JOB# REF# <br /> Department of Pubic Works APN CR 4 <br /> 7 <br /> EXP.DATE 7 <br /> VALID AOL TO DRIVEWAYS; <br /> (Applicant Name) STREET <br /> Mr-VIS P-0 -t -I- <br /> AREA QUAD J <br /> - kZAI <br /> TYPE 7; <br /> Z4 <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, to,Zip Code) <br /> 04 <br /> (Area Cocle.Telephone Number) <br /> Skii—ch(Detailed plam may be submifted) <br /> The KdBrSigned her*applies for permission to excarec-,CMWW&-dor otherMse encroach On County Highway Right-of-Way on <br /> the Sk1--of <br /> of feetimL. <br /> by Peftming the fd�kjwvrk(description of work): <br /> Work cwvencs on or about for a AM <br /> days. <br /> 1,the undersigned,certify 111M I am the owner of ms", operty,or am qualified 10 represent the mww and agree to do the <br /> for awoxim <br /> work described above in accordance with the rules aM reWations of San Jroquin County and subject to inspection and approval. <br /> rgnaE f pplicant-Title Date <br />