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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> e <br /> To: San Joaquin County JOB# 230077 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE /4 <br /> C L_I OR I A f I•EcE VALID 0 7 /4 DRIVEWAYS: <br /> (Applicant Name) STREETAREA U� <br /> 1�e E . 1�� til E 7T(` ST TYPE oc a QUAD �! <br /> SELL 1.102z- <br /> (Mailing <br /> .faGE � <br /> C (Mailing Address) FORMS <br /> 95NOTES <br /> �~ (City,State,Zip Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Hi hway Right-of-Way on <br /> the ��� :�t side of �c e^ approximately �fe mile Int <br /> °fms 'sby performing the following work( cription of work): <br /> Work will commence on or about <br /> " i for approximately Lo('J days. <br /> t,I)� i y <br /> I,the undersigned,certify that I am th ow�mf 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 /> ignafure of Applicant o Title ate <br /> FAACENTRALSERViCESCLEFUCALIPUSSV.WKWASTEPPS1ENCROACyAfENTPEFWIT4PUCAT10NDOC(09113) <br /> 1 <br />