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APPLICATION FOR ENCROACHMENT <br /> PERMIT <br /> PLEASE PRINT: <br /> Date X -Z LJ <br /> OFFICE USE ONLY <br /> TO: San Joaquin County JOB <br /> Department of Public works A.PN #_IL�2f-�T REF #------------- <br /> CR <br /> T,. EXP. DATE <br /> VALID oo 0 0 40 <br /> FApplicantNa'me) STREET DRIVEWAYS: <br /> j( 4 AREAG Q <br /> it <br /> (Mailing Address) TYPE <br /> FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> L <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on <br /> the sideofof approximately I-- I <br /> -/--------------------- feet/mileTip <br /> following work (description 1 J — Ption of work) : by performing the <br /> < <br /> —--------------- <br /> Zrk will commence on or about <br /> days. for approximately <br /> the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work des <br /> accordance with the rules described above in <br /> inspection and approval. regulations Of San Joaquin County and subject to <br /> ig/n6a:214 u r,a f Appli '� t __Title <br /> � <br /> 'MAS'nM-PS\FERSCEDL Date <br />