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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4- TO-- f 6 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN q 7-y E3.3�t CR# <br /> EXP.DATE "�../,s'-�j I(? <br /> �F�(L1� C S 11 L VALID I <br /> (Applicant Name) fi STREET 1 t� TO DRIVEWAYS: <br /> AREA QUAD _�V <br /> TYPE tot') W ,1 1 <br /> (Mailing Address) FORMS SSr' <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Telephone tum r <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the `S® v Ykf side of approximate <br /> y--- feet/mile <br /> by performing the following work(description of work): <br /> Work will commence on or about for approximately__ ::I days. <br /> Y <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 /> Signature of Applicant-Title J ' <br /> Date <br /> EiPUB•SV.WKVAASTER.PSIEVCROACHWWPERLCTAPPlICAnOH.00C(01=) <br />