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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: // <br /> Date 'I II C/J� OFFICE USE ONLY <br /> To: San Joaquin County JOB# Y WP73oj,{51 REF# <br /> Department of Public Works APN _ CR# <br /> UA(� n n EXP.DATE si <br /> 0) o,). r1C ()(,7'1f?tJ VALID T(6 7h 2— DRIVEWAYS: <br /> (Applicant Name) STREET <br /> f r AREA QUAD <br /> Po Box <br /> ` I V I TYPE <br /> CC /(Mailing Address) FORMS <br /> FORMS <br /> LA Y( 01 NOTES .f <br /> (City,State,Zip Code) <br /> a09- a34 -3.-77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PLA AJ SIC) AR61 ov 6u6ml-J-reo <br /> ( ox -' 9-01) <br /> The undersigned hereby applies for ission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ALL 4ide-of erm0 approximately a 000 feetf- i M117-4 <br /> of- �s, han aaolzao oyekP3SS by performing the following work(description of work): <br /> FI'1�i i20,40 SLGTfdIZ LA -,&, �ce�T f VVI"66 C6nNXr,2L)&710AJ <br /> Work will commence on or about QY 77for approximately 30 LAUKOJ& 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 IPUBSVWKWIASTER.PSIENCROACIIMENT PERMIT APPLICATION DOC (71M) <br />