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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: q <br /> Date 1 Z-- OFFICE USE ONLY <br /> To: San Joaquin County JOB# A lop-In, REF# <br /> �TDepartment of Public Works APN 506"tIZA6,CR# <br /> C J�,, u ,, EXP.DATE ! L <br /> ` t` «r�lJ�O(�Z� VALID 2— DRIVEWAYS. <br /> (Applicant Name) STREET D vE. �, <br /> iC.iu UO L1 L AREA STt-�Z QUAD is ' <br /> TYPE 73C—& dLES d72E,S <br /> (Mailing Address) FORMS <br /> 1—f Q SYIG �-�F 9 j 72-1l NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,constrict and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of , by performing the following work(description of work): <br /> 40 A1 eeeL <br /> PCS <br /> s 111F 6 <br /> c <br /> Work will commence on or about <br /> for approximate /!— 3 0--/Z days. <br /> f,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 A licant-Title 2 <br /> ate <br /> EVU84VYXUASTERPSE71ChC DA NT PET86TAPpLrAT"DOC (01008( <br />