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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT =;d 4�� M�° �•�� <br />J � <br />Hate r - l ` OFFICE USE ONLY <br />To: San Joaquin County <br />JOB # REF # <br />Department of Public Works <br />APN CR # <br />EXP. DATE <br />6 /l S,-2 U-I�t o/? <br />VALID TO DRIVEWAYS: <br />(Applicant Name) <br />STREET <br />U i3 a 7� <br />AREA QUAD <br />TYPE <br />(Mailing Address) <br />FORMS <br />r <br />NOTES <br />(City, State, Zip Code) <br />j <br />j <br />(Area Code - Telephone umber) <br />C 11C .'Ale 6•404, C 0in <br />I J <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />a Tip G • f� TU L 1( i`5Ti`lL G / %-1. 14. D IU S-1 i'1 S e T tit T r-f 7— r,o e --d.,/ <br />k, e%erraca7-- <br />�� uaa2rc_ -r-v t3eTT4tzc7--ed /Oeg C'� �. s. 7� 3 a- 3JO6, S. <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 approximately p feet/ 0 mile <br />of by performing the following work (description of work): <br />Work will commence on or after 74 - --� � <br />for approximately S- 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 />ILI <br />Signature of Applicant - Title Date <br />