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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '5,I <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public WorksREF tt <br /> APN CR# <br /> -�� EXP.DATE <br /> (Applicant Name) VALID TO / DRIVEWAYS: <br /> STREET <br /> (�L�.y .'i a'��_•: AREA <br /> S 7 .+/QUAD <br /> TYPE _- <br /> (Mailing Address)Address) FORMS <br /> NOTES <br /> (City,State,Zip Co e) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans maybe submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the N side of i <br /> of --� -- approximately. (Qbt/mile <br /> by performing the following work(description of work): <br /> Work will commence on or about <br /> for approximately, 7e) 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 ofApplicant-Title t`' <br /> Date <br /> r'l?U6,SV.Wi(fAJtSi:R.?S7<NCR0ACHr<fE�T PcRIAII,:poEICA-IC"l.OJC <br />