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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date — — OFFICE USE ONLY <br /> To: San Joaquin County JOB# 'tQ04S REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> CA 157 VALID TO tol� Ir DRIVEWAYS: <br /> (Applicant Name) STREET l9?D <br /> AREA LarkE,oR�t QUAD /VG <br /> t 9 � 4 S� -- TYPE `13626 P <br /> (Mailing Address) FORMS <br /> �� Z { NOTES <br /> (City,State,Zip Code) <br /> ` Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) S D- <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the to6ST to/STside of approximately - - r ,_ feet/mile <br /> of (�t �.,�„>.�, �-Cx-'&Eg2e�D by performing the following work(description of work): <br /> Work will commence on or about - - for approximately 3, V da s. <br /> Y <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 J <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> *�i;gnture of Applicant Title Date <br /> E 1PU&SV WKIMASTER PSIENCROACNMENT PERMIT APP:ICATION.000 (01106) <br />