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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Cj ) - ) OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN — CR# <br /> _ EXP.DATE <br /> GU 12 Lad a F r� fhA �GC�F � VALID D f d ! DRIVEWAYS: <br /> (Applicant Name) STREET b1dS D <br /> AREA QUAD <br /> l ru X %'i i TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,5EE 144FIMF_d- �C'P, L,,C C.bEk. EVEiyt <br /> i <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 feet/mile <br /> of- by performing the following work(descn ption of work): <br /> F CPI <br /> Rr�6fry mrk / rrm,yF fiyg: ��tr . <br /> J.:0£_pin ��nif C� C6 Piz) '-tt lt'� r %'i 37 <br /> - <br /> Work will commence on or about 15-1f days.Ippaey <br /> I, <br /> 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 /> q-L- i <br /> Signature of Applicant-Title J Date <br />