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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASEPP7RIIN1T: P�(i 309��36g6, <br /> Date Z%!►! 2)-, OrW13 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Z!5-�—J REF# <br /> Department of Public Works APN CR# <br /> PC, EXP.DATE Z <br /> VALID 14 Tb 2-11V4 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> KO w��+/ � AREA /�I�G�Q QUAD y� <br /> G t V/ �j TYPE <br /> (Mailing Address) FORMS Sb +mow -29 t %— , <br /> "ST � � NOTES <br /> (City,State,Zip Code) <br /> Ty- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-ofWa on <br /> the @ side of S. U ! approximately��j7 feet/mile O <br /> of by performing the following work(description of work): <br /> L IX, U, , , W 1�/ S <br /> Df <br /> s <br /> Work will commence on or about an 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 /> Signatur of Applicant-T' Date <br /> E�PU&SV5-IIVIJASTERPSIENCFIOACRMEM PERAIT APPLICATICUMM 101;M <br />