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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date aQi LA OFFICE USE ONLY <br /> To: San Joaquin County JOB# $ WV ki, REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE 1-/- 2(-7/ <br /> C �t� 1-5G VALID DRIVEWAYS: <br /> (Applicant Name) STREETc L <br /> AREA QUAD } <br /> 96 1a br) TYPE <br /> (Mailing Address) FORMS '�,� -:-c ket� <br /> NOTES <br /> (City,-State,Zip Code) <br /> :2 al <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Ck <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the t . .,> side of M a)&WAUNC approximately .3 ® 1 511 feet/mile <br /> of -itGp. nefl g& _,by performing the following work(description of work): <br /> y <br /> Work will commence on or about to k cif r qMj"3 iS ;,ZWfor approximately — S 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 /> CJ. (��U FaCA-MOS D,9-t-kr 19-2-20) <br /> Signature of Applicant-Title Date <br /> MICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACHMENTPERMIT APPLICATION DOC (0911J( <br />