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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (�® � OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( l 00 Q S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ?- I -l <br /> VALID • ¢ TO e/-1- 4 DRIVEWAYS: <br /> (Applicant Name) STREET /ha h eco s'/ �1 <br /> AREA Sfoc k n QUAD $E <br /> 131?1_,C>A sT. TYPE Bore <br /> (Mailing Address) FORMS 59/U/ <br /> NOTES <br /> Grp Q �{5s"0 <br /> (City,State,Zip Code) <br /> �&3— qg -7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> J6 <br /> - ---- - on - <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way <br /> the side of AA approximately feet/mile____ <br /> of L _L-�,0 F A h 0 -,:;r , by performing the following work(description of work): <br /> .I` A t-& ,2 1J L 6141�.r S A7 dA E SC3 ►nZ j "PO L <br /> Work will commence on or about 119 , for approximately /0 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 /> _23 14 <br /> Sijinature of Applicant-Title Date <br /> M.ICENTRALSERVICES�CLERICALIPU&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />