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r' <br /> 0 11 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datef OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> 56�:N C o r i-s mo) VALID z 12 11-4- TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> T17 � <br /> AREA QUAD <br /> P-W-t 5A 7" TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> CA 9 L4 522 <br /> (City,State;Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) @ Ll <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County H ig hway Right-of-Way on <br /> the rt9Gvi _side of approximately `.;0o fee mile ,Ale)-e7 <br /> of i 1 gra ,by performing the following work(description of work): <br /> -10 Y'_ <br /> E Imo- n u U-' 1: 5 eco C? <br /> Work will commence on or about -' u 1,L4 'Xg—fq 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 /> ignat'ure of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIRI&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(M13) <br /> 1 <br />