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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ) <br /> Date �—' I,® t 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Departmen';of Public Works APN CR# <br /> EXP. DATE L- p �VALID i *— TO i t2. DRIVEWAYS: <br /> (Applicant Name) STREET �- <br /> AREA QUAD �+ ,5 <br /> TYPE =6/c �t'�+. lr-ce,M-e o , - <br /> (Mailing Address) FORMS s w+t 1 AS <br /> NOTES <br /> (Cit:y,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plaris may be submitted) <br /> P- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_11J '0 J=VC' side of mz'1 'J S — approximately_ .Qt ** feet/mile <br /> of ��'- P--Pp 44 F by performing the following work(description of work): <br /> 2 <br /> R-6,+- <br /> Work will commence(:,n or about L211-T111 for approximately j 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 Applica Title -S— Sl� Date <br /> C.1i'U©-SV.WNIMASTERPSIENCROACMMEN'?ERM(TAPPUCAPON.000 (01108) <br />