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APPLICATInN`f OR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �,� � f r �'r R ( x OFFICEUSE0ll- <br /> LY <br /> To: San Joagwn County JOB# `'� � <br /> REF <br /> Department of Public Works APN RE# <br /> >� V <br /> EXP.DATE <br /> ., ��� 3��, `� t� li��", �?�(.�,• (_�,��i VALID <br /> %f``'<i�' TO DRIVEWAYS: <br /> {Applicant Name) STREET5 <br /> AREA !'r,�f <br /> TYPE QUAD <br /> `Z / x <br /> ----�- i 6 <br /> (Mailing Address) FORMS ,�tv7 <br /> NOTES f <br /> (City,State,Zip.Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans maybe submitted) <br /> ti € <br /> � f <br /> The undersigned hereby applies for permission to excavate,construct and/orotherwise encroach on County Highway Right-of--Way on <br /> the vrz a side of h - GA approximately 2.c <br /> { t oo<- <L y <br /> e-<1feet/mile <br /> > by performing the following work(description of work): <br /> fltf :10 0 CA :L t t p n+1 -e l A, Pipi <br /> Worm will commencekbn or about <br /> i or approximately_ days, <br /> I,the undersigned,certify that l 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 /> Sigh*ure of Applitant-Title ' ` <br /> Date <br /> E1Pu&sv.WKWASTER.?S%FNCROACNMENTPMATAPFLiGnON.Doc pimel <br />