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APPLICATION FOR ENCROAC14MENT PERMIT <br /> PLEASE PRINT: <br /> Date ( � � ,u±._ter j - _�,_� j �� OFFICE USE ONLY <br /> i , <br /> To: San Joaquin County JOB# _7 S T7 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE , �j <br /> A V V i9 f�E ) ( o I Lt [ VALID ,-,2 a( TO - DRIVEWAYS: <br /> (Applicant Name) STREET V I-- , <br /> AREA QUAD CSC- <br /> T-"f�i� I'I` _ TYPE <br /> (Failing Address) FORMS <br /> 5NOTES \`C( <br /> (City,State,Zip Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> � ry <br /> ± i <br /> ca _ <br /> ' . <br /> C r. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> side of Gni ; z ({ , approximately <br /> of ��1"I J ;; J pp Y fee mile _ <br /> by performing the following work( escdption of work): <br /> Work will commence on or about ; ` .t for approximately {; days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to Iresent 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 of Applicant o Title Date <br /> PA"'ENMkSBUCE=LMC VUBSV.WKVAASTERPSOE CROACH91Q7i PERA1RAPPLJCAT10KDOC(09113) <br />