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P X, :�C I ' <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4 ; OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Dt�$"a- REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> - VALID T DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA ,ts DGC—_ QUAD AI:W <br /> y - TYPE .k ltcG <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State, Zip Code) _ <br /> -' <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> e> 1 <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 approximately tr S` e mile %,--j <br /> of ; A_L by performing the following work(description of work): <br /> Work will commence on or about_ /f for approximately 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 Date <br /> E:INUESV.WKIWNSTER.YST..NC?.OAC]il,CNT'':RMITAI'PLIGATION.DDC !01M) <br />