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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /,-' -/1-/0 . — <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 732 REF# <br /> Department of Public Works —APNCR# <br /> 1-7 --r _(�, EXP.DATE <br /> VALID <br /> TO <br /> (ApplicantName) STREET To DRIVEWAYS: <br /> AREA <br /> TYPE QUAD <br /> (Mailing Address) <br /> FORMS <br /> NOTES <br /> /a <br /> -TC-1-t4-- <br /> Y,Sj� <br /> ate,Zip Code) <br /> 72 -7e) <br /> --(A�reaCode--Telephone Numb— <br /> er) <br /> � etch(Detailed plans may be submitted) <br /> I a b <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately <br /> of-—-------------- feet/mile. <br /> by performing the followinq�Vork(desc6pfion of work): <br /> IC C' <br /> WO'k�Wlll commence on or—about <br /> for approximately,_ ----days. <br /> 1,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 ab9.Y .n acco ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> .5 <br /> Signature­­Apprlca-n—t <br /> Date <br /> E',PUB,SV WAMASTERPsF,4CRC�3iV� <br /> pj F1:FCj,1 ppp3r4,- <br /> V,C.00 <br />