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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dateg r; j. to 2 i t q. OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN _ CR# <br /> EXP. DATE ? J <br /> C.A r n:ct VALID T DRIVEWAYS: <br /> (Applicant Name) STREET 14>J <br /> AREA QUAD Sw <br /> b(�0 C&V1n i n t3 a"U n , X6-7 5-6 TYPE / aunG{ &LGWu <br /> (Mailing Address) FORMS L <br /> NOTES <br /> (City, State,Zip Code) /s lyl Al?' e — <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway t-of-Way on <br /> the :5.5.Aside of 62 rra4 Hbl l o w R1 approximately 3 mile L` <br /> of JS rp o 4 4.1l.w RA , by performing the following work(description of work): <br /> Work will commence on or about /A for approximately o 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 /> a4l?r 14 F�- 7- d-o <br /> Signature of Applicant-Title Cn�;„e�� Date 4 <br /> Id CEATSiUi5Efi".CES`CLERSCALIPUESV.1'rn:'dASiERPS.E:XrOACMfttlf PERXT A PUCATJ0;l DOC (Jt3J <br />