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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7 z OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1/DDDR REF# <br /> Department of(Pu--blic Works APN CR# <br /> l �" 4� a '" �,' '� VALIDATE 0 DRIVEWAYS: <br /> (Applicant Name) STREET �450�,�Q <br /> AREA AG�Y_ QUAD !ti <br /> TYPE E l <br /> (Mailing Address) FORMS lye - <br /> NOTES T— <br /> •' CA <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> kV0 � <br /> The undersi nedereby applies for ermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the _t4 <br /> side of �. , �.'Q� � approximately ' 7D e m(le ° rc <br /> of JAc ,:e4-,1 4 Wy, � c ,by performing the following work( ascription of work): <br /> Y !"tA !D- IV V ll /AAVWAXNX Y— WMA 6001 �UJ <br /> a. <br /> Work will commence on or about 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 /> 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:SPU&S VftMOTERPMENLROAUiMENTKRWTAMI=TIDNApC(DAUB) <br />