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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /S~ / OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> � EXP.DATE 1 <br /> v/�/ Ve c � VALID fTO DRIVEWAYS: <br /> (Applicant Name) STREET o 1 . <br /> AREA p QUAD <br /> TYPE ' <br /> (Mailing Address) FORMS Wye ,p �7 <br /> NOTES <br /> r/1 �� 1 <br /> (City,State,Zip Code) <br /> A L <br /> w po% <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies.for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ..i O.O Ti/ side of c/ G approximately Ol> fee mile <br /> of � oU7// f fI?gLVf —U v by performing the following work( escription of work): <br /> ;ii2 f�Tc,-' r S81_6115� <br /> Work will commence on or about &?-e D/, 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.%PUBSV.%M$.(ASTERPS%EiiCROACWFr11TPEAA4TAPPLICAT104Doc(01M) <br />