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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> }G _'", c��f j�_ VALID 4 /4 0 -7 Z>< 14 DRIVEWAYS: <br /> (Applicant Name) STREET �!AgOz-r> 6 <br /> AREA F5G41oA./ QUAD Sg ' <br /> TYPE 6MP, J2e"A.0 GLDSL� <br /> (Mailing Address) FORMS 5S1J <br /> NOTES IF <br /> (City,State,Zip Code) <br /> P P CG�u e Q/J -77P,-921'4 <br /> 7-0 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,� 'p ,I two> .✓ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feeftle <br /> Of by performing the following work(description of work): <br /> Work will commence on or about 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 abo evin accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E.IPUBSV.WKWASTERPSIENCROACHMENT PERMIT APPUCATIONDOC J011M <br />