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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> JOB# 'T3oOS2-s REF# <br /> To: San Joaquin County APN CR# <br /> Department of Public Works <br /> EXP.DATE —�S= d DRIVEWAYS: <br /> VALID '1-l-2t,Lt1 TO "lS <br /> (Applicant Name) STREET I <br /> AREA 3 1 QUAD _ <br /> 4 CLI����-mac' '(11+17 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> wk':1 -naO -5 6 . <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 C side of i 1B) approximately -110 ('mile <br /> of by performing the following work(description of work): <br /> , <br /> UT" <br /> for approximately days. <br /> Work will commence on or about_ <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 /> �Tiitl� <br /> YL- 41Z L1 <br /> ignature of Applicant- ate <br /> E:WUB-Sv.WNMASER-PS1ENCROACHMEN7PMMrr APPLICATION.DOC (0110A) <br />