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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �.� ; �,� ) OFFICE USE ONLY <br /> To: San Joaquin County JOB## 7? 7? REF.# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> Cd L 1 L Q Qti i A f t.E��2 is 11E VALID $�� TO DRIVEWAYS: <br /> (Applicant Narbe) STREET rI i26Af�r'�fyE <br /> 1 <br /> _ AREA STdcraw/ QUAD <br /> -A(0 c� E . t )} �� E 7F I f'` ST TYPE 'BE L tL 140M <br /> (Uailing ddress) FORMS Ss29 nclr a �r 0/rte <br /> K-T O NOTES _ _. <br /> (City,State,lip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> r <br /> The undersigned hereby applies or permission to excavate,construct andlor otherwise encroach.on County Highway Right of-Way on <br /> the side of «L �,. —approximately?��? feet/mile <br /> Of >n e z. by performing the following work(description of work): <br /> rh <br /> x U. _. <br /> Work will commence on or about O r for approximately r days. <br /> (V 15 )4 <br /> 1,the undersigned,certify that I am the owner of the respective properly,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 ofApplicant-Title <br /> WiCENMIS 8MCEStGb21CALW13SV.iNKIIASiERP51�ROACH.15�iTpMfIrAh'L=7i0A00.:(C1U7 <br /> 1 <br />