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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date P OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 i p ,r REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ <br /> VALID 0 iz- t© fo y2S� 1D DRIVEWAYS: <br /> (Applicant Name) STREET u k <br /> AREA Qe� q QU D SW <br /> 19 u lav�C fn TYPE " px1 b4S <br /> (Mailing Address) FORMS <br /> NOTES <br /> ) iecjuuA <br /> (City,State,Zip Code) <br /> 2,Q '1. - c�7av YyC) <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_ 6 0-1 1F side of MA-r-6 N i 5 Nle g/Q approximately 7 co fT feet/mile <br /> of_ 6 Lo c y-fJ /Z�a _ , by performing the following work(description of work): <br /> 45)9Ag c, <br /> Work will commence on or abouty c%T l2, Tot 3 for approximately /?1 L),?,jos 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 /> Eo' <br /> ��Sig�na#ure of Applica Title �J� Date i <br /> E.WLSSV.IAM ASTEP,MENCMACHMENf PEFUTAPPUCATION.DoC (011M <br />