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f <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f - '�- 1 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# k`u2o�< REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2.-I,1. 90 C1 <br /> i2n), G VALID DRIVEWAYS: <br /> (Applicant Na e) STREET rSrn\col�sk� <br /> AREA QUAD N f- <br /> 10. 600 -7-3 TYPE un V <br /> (Mailing Address) FORMS ,$V 1.0 <br /> NOTES 4hY�CY tt✓ C <br /> (City,State,Zip Code) <br /> ,9)< <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted)) <br /> Cs6- �-�l�' <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the rH sidaof 65CAUNi_ 3t�woJ-A P-0 approximately /07)7Deetlr*Ile <br /> of by performing the following work description of work): <br /> Work will commence on or about / 117 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 /> Signa ure of App scant-Ti fe Date <br /> M:\CENTRALSERVICESICLERICALIPUBSV.WKWASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />