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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /j t �)4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# r_� '�c�'� REF# <br /> Department of Public Works APN CR# <br /> `rI ,(�� EXP.DATE <br /> /Ll�(� AA�� VALID ( „2DI4TO (-L, t,-2p DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA �, <br /> c�G QUAD r <br /> C�iLJO l <br /> tot LE 1 TYPE p <br /> (Mailing Address) FORMS 4t- L). <br /> CA q n t`0 NOTES �- <br /> J1(}liK�t V (City,State,Zip Code)) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> A-FArt" � <br /> S <br /> The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the S side ofZ-cQi7_S� (DC7 _approximately ` feet/p4 _ <br /> of - b performingqte followin work(description of work): <br /> J -dJ <br /> 'Work will commence on or about _for approximately <br /> days. <br /> 1, 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 /> Signature of Applicant- i e Date <br /> • n.'c J;_;: ;,FFK'A'FiF._'J:Yr.iMP.c.ER PS''.EI;:,nO.\iHWF:' cP.W1'APi.C..RI`.Cn <br />