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PLEASE PRIAPPLICATION FOR ENCROACHMENT PERMIT <br /> NT: <br /> Date ( <br /> OFFICE USE ONLY <br /> To. San Joaquin County <br /> Department of Public Works JOB # REF #$ <br /> APN <br /> O�Y1 L 9 -I/I EXP. DATE CR <br /> A/ir� //z"C <br /> VALID �_., <br /> (APPlicant Name) .^�'= TO DRIVEWAYS: <br /> , STREET4341 <br /> �,1 <br /> ,�r AREA <br /> TYPE QUAD <br /> (Mailing Address) <br /> ,_.�drrLA <br /> FORMS <br /> /// ✓f Y d r� i NOTE <br /> (Cit <br /> G2Y� State, Zi.p Code) <br /> 4 _(2,L 9) •5 3 I <br /> (Area Code - Telephone Number <br /> I <br /> tch (Detailed plans may be submitted) <br /> The undersigned hereby applies for <br /> otherwise encroach on coLnt permission to excavate, <br /> y Highway construct <br /> g way Right-of-Way on the and/or <br /> of ,v _ _ approximately ' side of <br /> / -- --- feet/mile <br /> 1f r <br /> following work --�_ �1—�, �'r.�,r. - 'c'r, /� <br /> (description of work) : by performing the <br /> Work will commence on or about <br /> -- days, for approximately <br /> I, <br /> the undersigned certify that I am the owner of p <br /> represent the owner and agree to do tthe respective Property, <br /> accordance with the rules he work described above in a <br /> inspection and approval. regulations of San Joaquin County and subject to <br /> G� <br /> Signature of A t•tdL`� <br /> t PP icant - Title �3 <br /> MasrLz.rs Pass�IDL �>� Date <br /> (6/OGi <br />