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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: i <br /> Date �' �� OFFICE USE ONLY <br /> I <br /> To: San Joaquin County JOB# du,S REF# -_— <br /> Department of Public Works APN CR#EX . D - <br /> VALID ATE — o /1 TO _ DRIVEWAYS: <br /> / a <br /> (Applicant Name) STREET D,L <br /> AREA ,i/ QUAD L�7- <br /> 0 TYPE A0141> <br /> (Mailing Address) 1 FORMS <br /> 155a NOTE <br /> -'0Jl, _ I if/ot/ 2l? 2,o/b ,�1.�1 •.�© A Al � 2.3 a Py <br /> (City,State,Zip Code <br /> rea Code-Telephone Number <br /> Sketch (Detailed plans may be submitted) — <br /> i <br /> I <br /> I <br /> The undersigned hereby applies for permission to excavate, con trust and/or otherpise encroach on County Highway Right-of-Way on <br /> the side o � r '�� feet/mile _ <br /> of <br /> - by perfor the following work(description of work): <br /> Work will commence on or about_A t for approximately AL clays. <br /> 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 /> mow+ t o <br /> gnature of Applic j•Title Date <br />