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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date j OFFICE USE ONLY <br /> 10: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 1 I E� c�`(L u I Q,C VALID -Z- TO DRIVEWAYS: <br /> (Applicant Haeme) STREET <br /> AREA S�- QUAD` <br /> (o �_A F)9 U TFE ST TYPE Tv- - <br /> (MailingAddress) FORMS LV Izz / Z y <br /> L�-l ® � NOTES <br /> (City,State,Zip Code) <br /> '(Area Code=Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for rission to excavate,construct and/or otherwise encro�chon County Highway Right-of-Way on <br /> the Nor-I-h side of approximately JQ ?escnption <br /> mile (�lhc3� <br /> of t-�.'r c ,by performing the following work( of work): <br /> '- n,a-l- 1� �x• tom( ,�1� 1 ('� �� <br /> Worlc will commence on or about for approximat ly <br /> days. <br /> C �I ► s I y <br /> I,the undersigned, certify that I am the owner of the respective property,or am qualified to repr sent f e owner and agree to do the <br /> work described above in accordance wifh the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> AD <br /> ignaturre of Applicant o Title to <br /> "'."ENiRAI_SERVICESICLE ICAL1PU3SV.WKVMSTERPS1EI.CROACH,IEI.RpERAiITAPpLICATIORDCC(09113) <br />