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APPLICATION FOR ENCROACIHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# _ <br /> Department of Public Works APN CR# _ <br /> VALID ATE 'y 2 � <br /> 0- L4 _ <br /> �_ T 0 DRIVEWAYS: <br /> (Applicant Name) STREET ;0 yEe len S Aw,;9 Ac Z)i, <br /> -� -, AREA J/_�I,*Al QUAD <br /> J 79 �- TYPE 7KftO,, <br /> (Mailing Address) FORMS 15z,) _ <br /> NOTES �- <br /> ����✓1' (City,State,Zip Code) <br /> -67cl— $'cs'afc <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 /> the side of approximately feet/mile <br /> Of 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 /> work described ab y'e in accordance ith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> EIPU"NWKVA45fRP51ENCROACNI,1ENf PERWTAPPl1CATIONDOC(01108) <br />