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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> ✓ - IU <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 73 07 r3 REF # <br /> Department of Public Works APN CR. # <br /> EXP. DA IC O <br /> FIL` L Q F-) _A � l IT VALID l IC 0 f 10 DRIVEWAYS: <br /> (Applicant Name) STREET /pl<�� <br /> AREA QUAD fV — <br /> ;, � TYPE t �� <br /> (Mailing Address) FORMS <br /> NOTE <br /> ILLI EJ � R , 15'2 ) C <br /> (City, State, Zip Code) <br /> �2y49r� y 7 K - V 03 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> VV I <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the Rs�c i � side -of <br /> dal �;� �; � 'I <' �_ ; r. <br /> D approximately feet/mile <br /> f 47 i; A'1^; a� r- T r� ~1 ?� I J i�►i by Performing the <br /> following work (description of work) : } � t�- , tom '" a r <br /> 71 <br /> 17 - <br /> lt'"� 2- i <br /> LEL <br /> Work wi")ll commence on or about <br /> days. <br /> for approximately <br /> . <br /> I, the 1-mdersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature ol Applicant - Title <br /> Date <br />