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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date — `°, -- ! - <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# fjQ���'` REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE // <br /> 1141cAA7t61 ('vC VALID t TO DRIVEWAYS: <br /> (Applicant Name) STREET , <br /> AREA QUAD , <br /> TYPE �!Lrw� <br /> (Mailing Address) FORMS OX/'�r,�/ <br /> NOTES <br /> (City,State,Zip Code) <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 I`.a side of 5' <br /> —� � approximately D` 12 ti ee 'mile N vy-� <br /> of(the-}��n.k y,^ t �n fihCLI14 F �3 vy by performing the following work(description of work): <br /> _ <br /> Work will commence on or about t > for approximately 1 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 /> ignature Applicant-Title - Date <br /> E%PUB SVWKWASTER PS+E NCR OACNMENT PERMIT APPLICATION DOG (01/00) <br />