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f5'1101e'�l <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date2C� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 +y.-� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3 <br /> VALID /I 0 2 DRIVEWAYS: <br /> (Applicant Name) STREET ;ea, <br /> � ) AREA rH,olb QUAD ,{/E <br /> TYPELT , <br /> (Mailing Address) FORMS , <br /> NOTES <br /> -ity,State,Zip Code) <br /> (Area Cod;-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PK S0e>4.02.1 J <br /> pe-c- 120)0XP <br /> — <br /> g <br /> The undersigned hereby applies for permission tQ excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 9&_side of �A�li9,b7' approximate) <br /> of Y feet/mile <br /> by performing the following work(description of work): <br /> Work will commen69 on or aboutfor approximately <br /> 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 /> r <br /> �(4 Pq <br /> Signature of Applicant-Title lm� s_ 4 <br /> Date <br /> UBSV WNIMASTER.PSIENCROACHAENT PERMIT APPLICATION DOC (01108) <br />