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P 'LI PLICATION FOR ENCROACHMENT PERMIT l <br /> A F C <br /> PLEASE PRINT: <br /> Date I G Iq I ) I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7,36d .�� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE !S'/Z <br /> (�(j �i, i VALID 71-1112, TO y DRIVEWAYS: <br /> (A ical nt Name) STREET i,E7xr <br /> AREAQUAD <br /> TYPE !2zLdz11!!KLGf� S <br /> )a:. n Address FORMS <br /> �{,f� Sg NOTES <br /> (City,State,Zip Code) <br /> Z - y4-2& <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigne hereby applies for permission to excavate, co struct and/or otherwise encroach on C u my Highway Right-of-Way on <br /> the � side of_ �2� fJK approximately feet/mile <br /> of x by performing the following work(description of work): <br /> IV,, New !` . l� �� � 17�STI°P--,C)-11 V,.Pci <br /> 12,11 z <br /> Work will commence on or about 7 ?— for approximately 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 /> w described above i ordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> gnature of Apfidnt-TitlX date <br /> E:PUB-SV.WMMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (0108) <br />