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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dated 23 13 OFFICE USE ONLY <br /> To: San Joaquin County // JOB# <br /> Department of Public Works REF# <br /> �'I�a o/ �''S�Nf APN <br /> CR# <br /> EXP.DATE <br /> ��-OhsoTd��rop K 5 3 '°��J6Z VALID O 29 '6 <br /> T �S 3 DRIVEWAYS: <br /> (Applicant Name) STREET HITT * <br /> Q / <br /> -let <br /> AREA QUAD �_ <br /> 1 O AC CJD / et TYPE BA T.�l/X 3'4'rE <br /> (Mailing Address) FORMS :-:%'ro4a SAI& <br /> SL LN qs� NOTES <br /> ro rd (City,State,Zip Code) <br /> -630 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> e � <br /> The under i ned hereby applies for permission to excavate construct and/or otherwise encroach on <br /> �ounty Highway Right-of-Way on <br /> the side of 6rar.� L,�,,.� ', approximately 1O[� feet/mile <br /> of by performing the following work(description of work <br /> . +✓ 44? <br /> 01 G r 4 <br /> J044 A "*--V' <br /> a <br /> Work will commence on or about ! eop0 1111-411111 <br /> t or approxima el _days. <br /> PRI re- y 3 4/t t KS C.,e otvr a p h <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the ow)r 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 /> S' ure Appli -Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WHW,ASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />