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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ,l ", , OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE f S <br /> ' VALID ! TO IS' ! DRIVEWAYS: <br /> (Applicant Njme) STREET GPlI <br /> AREAQUAD <br /> TYPE <br /> (Mailing Address) FORMS 1,✓,✓tv,z ,�-2� <br /> NOTES <br /> (City,State, Zip Code— ) '— <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ` 4,4 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ki side of tt sn" <-, T approximately , `/mile Q <br /> of AS Irks _ by performing the following work(description of work): <br /> Work will commence on or about I for approximately I C = — 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 /> Signature of Applicant-Title —T Date <br /> E:L JB-SV WY',MFSiEP..PSkNC30FC!'.ME�7?E3;11,1T,\F?LiCATIOfLUOC �^;v2) <br />