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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �1 - ZZ �� — OFFICE USE ONLY <br /> ' <br /> To: San Joaquin County JOB# REF#—W� �(Opb,� <br /> Department of Public Works APN _ CR# <br /> EXP. DATE 12- <br /> To <br /> ZJ o—.--.----.---.. -- VALID f I -2yl 2- TOZPs_t2_/ DRIVEWAYS. <br /> (Applicant Name) I STREETAREA QUAD <br /> TYPE --- <br /> 7� (Mailing Address) FORMS <br /> i <br /> _ NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) 1 <br /> Sketch(Detailed plans may be submitted), <br /> i <br /> I <br /> I � <br /> I <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—�:/.�I'L7� Lac, 2� approximately / ' feeUmile <br /> Of /Z�,c.r ,�►� _ — — by performing the following work (description of work): <br /> Work will commence on or about �r1���--�,c Z — for approximately 7 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 1,JB W WKUJASTER;'SIi:M1C�Y:ACivaIY.I I*:Roil nnR GI-(N.C(H: .518) <br />