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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB <br /> Department of Public Wor ks - REF# <br /> APN CR# <br /> N <br /> EXP.DATE / �3 <br /> �'�� J Cmc ccR.de , l <br /> (Applicant Name) VALID / 0 — DRIVEWAYS: <br /> STREET <br /> 90 �X 0 TYPE 4 AD <br /> (Mailing Address) FORMS --- <br /> �+VGrW1 U r GC-n- �Lf r- g_ + NOTES <br /> (City,State,Zip Code) 1 <br /> 25 3-7-3 (33"70 <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ty'GL_" t <br /> ; <br /> Ir T LA!y) t96-n'::. SSS- l <br /> I <br /> I <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 <br /> of -- approximately_ _ feet/mile <br /> by Performing the following work(description of work): <br /> T-15 ti <br /> Work wfl commence on or about 1 <br /> for approZimately 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 /> �• .XLi ra4tf <br /> Signature <br /> of Applicant-T- — <br /> Date <br /> e.'FL35V AIVAS.R PS'VXRCACn!eJ cER!AT <br />