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a1; '22."21 Cl Cl,._= 1220953-365 04 10LUR THE SKIES PAGE 01!03 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT-, <br /> Date ��-�-�1 1 �-� �Q j � <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB# �!�{I REF# <br /> fAPN CR# <br /> �j _ <br /> t ! yam-- fC 1 EXP.DATE o �G <br /> VALID DRIVEWAYS: <br /> (Applicant Name} STREET �+ <br /> o X f IPE --� QUAD <br /> (Mailing Address) FORMS <br /> _,Q, q NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number} <br /> iSketch(Detailed plans may be submitted) <br /> i <br /> I <br /> i <br /> J <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 <br /> of approximately feet/mile <br /> U by performing the following work(description of v�ork): <br /> Work will commence on or about <br /> for approximately days. <br /> I,the undersigned, certify that I am the owner of the respective pro <br /> perty,or am qualified wo cribed above in accordance with the rules and regulations o San Joaquin n Couno and su nectto inst the et and agree pro the <br /> _ � County bJ inspection and approval. <br /> Signature of Ap rrtte �� " ` •� l <br /> Date <br /> tai'V?iuV.ttiA14u'.ST_i;YS;"cNCnOACFMQN�oERMI'APR;1 .,Ti�`CDGC j7106i <br />