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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN , CR# <br /> EXP.DATE / 2- <br /> i fid-��: (t VALID &'&11'Z- TO it DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA Za/II, LAI QUAD` ` <br /> Ld4..29 TYPE �r '7Cit <br /> (Ma!Mg g Address) FORMS <br /> NOTES <br /> q 7� <br /> (City,State,Zip Code) <br /> ( .0 ) H7 _ 3-11 d <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The under ig d hereby applies for permission to excavate,construct and/or otherwise encroach on CountV Highway Right-of-Way on <br /> the `' side of 14'1r,��J approximately feet/mile <br /> of ^—� by performi g the following work(description of work): <br /> Work will commence on or about 44 pe- Z for approximately 04P 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 abov in accordance wi the rules and regulations of San Joaquin County d subject inspection and approval. <br /> S 3© � <br /> Sign ure of Applican - D e <br /> E:1PU STER.PS\ENCROACHMENTPEFMITAPPL,CATION.DO7(01/M <br />