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t , <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ! yy OFFICE USE ONLY <br /> To: San Joaquin County JOB# (?0,-e7,SQ5-M-)7REF# <br /> Department of Public Works APN CR# <br /> ,Q /�I � EXP.DATEy -�5- 20!,-k <br /> // 7; l��5 VALID TO l 0-/S_Z��1.� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD � <br /> TYPE �1_� C OMT <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> tor' S—/-7cg. 1--7— <br /> ,36Z- <br /> (Area <br /> Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> OzGT-L-�-TaSG � ��3 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 1i side of L- Ato7' /Z approximately .S00 fee mile in-St <br /> of�,1„� it. f:S by performing the following work(description of work): <br /> enN <br /> S <br /> Work will commence on or about for approximately days. <br /> I, the undersigns , rtify that I am the ow er of the respective property, or am qualified to represent the owner and agree to do the <br /> work descri a ve in a rdance�with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 7 <br /> Si tore of Title Date <br /> AIS.CENTRALSERVICEMCLERICALIPUB-SV/STERACHI',IENTPERMITAPPLICATIOnI DOC (0910) <br />