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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date j �� � L� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1((x7 p'5� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1:31—l b- go/H <br /> VALID TO 3—f 6 Z _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA J Gv` QUAD <br /> P U Cru TYPE <br /> (Mailing Address) FORMS <br /> n NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> !SeF� �'14C-qe b <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 '1 is�,�rr tyJ�?�i inn Sapproximately / tee mile <br /> of .r - J, ��;14=%>r 1W. , by performing the following work escription of work): <br /> y YS <br /> Work will commence on or about r�7A�-c:-t= —fes; 2i 4 for approximately Z_ 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 /> y <br /> Sighs-ture of Applicant-Title Date <br /> M.ICENTRALSERVICESICLERICALIPUBSV.WKIMASTERPSIENCROACHMENT PERMIT APPLICATIONAOC (09113) <br />