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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ q.-y-(�L, OFFICE USE ONLY <br /> To: San Joaquin County JOB# //ppdS' REF# <br /> Department of Public Works APN <br /> 11 CR# <br /> l JI 112 LAI i nF F1�-�-tmR Srt E r EXP.DATE �J 2 <br /> ! QRS .ry VALID T DRIVEWAYS: <br /> (Applicant Name) STREET A rGY/5 ,QpR <br /> AREA �,y_D,Qjr/r-p QUAD <br /> TEyyP ,�aR� GUrz� <br /> (MailingTYPE Address) FORMS <br /> &/,v i� NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE gk6l� d <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of--Way on <br /> the side of______ <br /> of approximately feet/mile <br /> /E�7D 2ta AbAd 0 —1 ZRE by performing the following work(description of work): <br /> zdD P/n ' vim' <br /> •� PM <br /> Work will commence on or about <br /> 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 /> �a alw2 , AA'1L - <br /> Signature of Applicant-Titie `'Date D <br /> E:IPUMV.WKWASTER.PMNCROACHNEPTrpERwTAPpLICATIONDOC (01108) <br />