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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> L` L' OFFICE USE ONLY <br /> To: San Joaquin County JOB# AV05' REF# <br /> Department of Public Works APN __ CR# <br /> EXP.DATE 1p <br /> Unto - I�o��r5 VALID .Y/ -to � � _ DRIVEWAYS: <br /> (Applicant Name) STREET 14oi--r ' <br /> _( AREA � 111 c4en QUAD l- ' <br /> hftk t C (y <br /> L" '4 TYPE -IkD AaCZo u R A& ' <br /> (Mailing Address) FORMS ) <br /> 5 NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> theside of approximately feet/mile <br /> of _ d , by performing the following work(description of work): <br /> Work will commence on or about 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 /> rk described abov in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> s d 9W <br /> Si re o Applican -Title 0o0ykp(_�� Date <br /> E:1PUBbY. PEWTAPPLICAnMDOC(01M) <br />