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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date \C) 23 - \3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# &11j 0 ' REF# <br /> Department of Public Works APN CR# <br /> (�` EXP.DATE <br /> v�e �h�er L��jc� eys �``� VALID 5 /7 0 74,11 <br /> / DRIVEWAYS: <br /> (Applicant Name) STREET V/7 I <br /> AREA QUADS ' <br /> Q) TYPE 6k Ir" 094 <br /> (Mailing Address) FORMS <br /> NOTES <br /> 01 Awl A4.p ee�,e,-6 <br /> (City, State,Zip Code) <br /> �RiL! � l7 ���� Flo. �:rx�A.,�✓. <br /> 2A�-�� - 235 Ta r:• �9.�!. <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed p�lans__tmay be submitted) <br /> C <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side ofNG4ri ,L6A af- AD. ,/-PX approximately feet/mile <br /> of by performin the folio,�ing work(description of work): <br /> - <br /> Work will commence on or about-,- A 2-on for approximately Ars- q7days.- <br /> 6 <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 /> Signature of plicant-Titl - Date <br /> YAFORMS 6 TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc(ONS) <br />