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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:L M p <br /> Date ©G.r a D Q-r 1 2 0 / 7 OFFICE USE ONLY <br /> To; San Joaquin County JOB# REF# <br /> Department of public Works APN CR# q$ <br /> C EXP.DATE (�-1 Lal� <br /> PC <br /> -�.ro �Afpllc.nl <br /> - VALID - -ZOL T L(-i � DRIVEWAYS:�� me) STREET w P� • <br /> 5-18 l 7 S t, , S& S 1g . <br /> AREA <br /> E QUAD <br /> (Mailing Address) FORMS W W <br /> 70 NOTES <br /> (City,State,zip Code) <br /> 303 - g 7 S foo x Jo <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Rtht•of Way on <br /> the side of ' approximately feef/mile <br /> OfV C) , �perlforff)In,the fullawing�wo* escription of work): <br /> Wont will commence on or about_/ 0 ^/ 7- i for approximately 2 days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am quallhed to represent the owner and agree to do the. <br /> work described above in accordance with the rules and regulations of San Joaquin Countyand subject to inspection and approval. <br /> Ignature of Applicant.Title Date <br />