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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J 7 J OFFICE USE ONLY <br /> To: San Joaquin County JOB# 'Jg00?9 REF# <br /> �J Department of Public Works APN CR# <br /> EXP <br /> VALID ATE <br /> /0 <br /> (Applicant Name) s ,tQ - TO DRIVEWAYS: <br /> 1 / 15' <br /> STREET <br /> TYPE AREA ��Gy QUAD <br /> — may/ <br /> �r�,P6,�iiyD 72iNNEL, <br /> (Mailing Address) FORMS <br /> NOTES <br /> --� 2 - ov <br /> ---- — -- - <br /> (City,State,Zip Code) <br /> Area Code-Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> �---- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of ay on <br /> theF=csn1 side of_ 'ice ,4j approximately <br /> of ' i.✓677` ,�� 1,� by performing the following work(description of work): <br /> Work will commence on or about for approximately 2ma.�✓-� <br /> � 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 /> /T A, <br /> n e of Applicant o Title Date <br /> PAaCEWRALSERVICESCI-EICALIPUBSV.WVAASTER.PSIENCROACH97ENTPEFiMITAPPLICATION.00C(U?HS) <br /> 1 <br />