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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date i OFFICE USE ONLY <br /> To San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID0 2 Jj DRIVEWAYS: <br /> (Applicant Name) STREET 44 � <br /> AREA 5f73C4I!T4P1 QUAD <br /> RACE, E TYPE EA DAi P�__-__ <br /> (Mailing Address) FORMS 5 yyJ <br /> 93720 NOTES <br /> CA <br /> ( ity, State,Zip Code) <br /> (559)T347_-5;z1(0 NAek,. -- <br /> (Area Code-Telephone Number) <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 N0LV4A- side of _approximately �ji�E feet/ T <br /> of y—wY C1!1 — by performin�q the following work(description of work): <br /> RC2'U �.1T d1`1 <br /> Work will commence on or about for approximately_ s.da <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 /> —-A*�_ - <br /> Signature o�Apicant-Title- Date <br /> L WUB`.Y WMIW';'ERPS�NCRUACHMElR PERMIT A PPS I CATION:X}; I[1N'I <br />