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r . <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB# Qaj REF# <br /> Department of Public Works APN _ CR# <br /> _ EXP.DATE /,5'J <br /> VALID 5 0 S DRIVEWAYS: <br /> (Applicant Name) STREET woerr <br /> AREA lfiCk?60 QUAD �,LS <br /> TYPE Z -.9--L[-t&aJ za6 <br /> (Mailing Address) FORMS eS ww, Z9 <br /> NOTES <br /> �1 (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) JAC,�r <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 64 c.:T side of /V, approximately_SO fee it o- 4,—5-4S <br /> by performing the following work(description of work): <br /> ul1y6 17 <br /> �NSi,4,LL, ,,✓= <br /> Work will commence on or about_�' !- i�t 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 /> S' nature of Applicant-Title Date <br /> M:ICENTRALSERVICES�CLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />