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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' - -4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?3tyOS2r REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID to z / DRIVEWAYS: <br /> (Applicant Name) STREET G <br /> 't' AREA �-�n/ QUAD e <br /> 1` �bx. T�CE TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> 2 <br /> ( ity�Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S-v ' / <br /> �1 k <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ..&109M§!1 r side ofC�l�.�.�►Suwts'Q. — V�{� approximately e (000 Q�mile <br /> of C�►,a►E�Zb10E� rl,�,�yE QnC N& �- by performing the following work(description of work): <br /> QjLyc' "r ECAC A-T�Cc�NS <br /> Work will commence on or about_ 1"\ — �» for approximately days. <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 /> MIT <br /> 9-24-2BttJ <br /> Signature of Applicant-Title Date <br /> E IPU&SV WIMMASTER PSIENCROACHMENT PERMIT APPLICATION DOC (01m: <br />