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i b l H-a5 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date bi( OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 �V S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> P C VALID ( - -l TO O- - DRIVEWAYS: <br /> (Applicant Name) STREET rQrl fir,{ <br /> AREA ,_ QUAD <br /> kd. TYPE <br /> ailing Address) FORMS S 11W 1Z <br /> NOTES <br /> (City,State,Zip Code) <br /> 925 2.414-_ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <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 &U• k approximately feet/mile <br /> of , by performing the following work(description of work): <br /> i S i CLtt 0 kx iQ i C X ' <br /> Sz,X Ca'yc'bbnl _ 2. LRyJ20-->7 RV ,'LL cYud1--7 470 do <br /> 42a�rr •f-..c ern p LF i's rL-e e n( <br /> Work will commence on or about for approximately /!�i 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 /scribed above. ccorda ith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature Applicant-Title Date <br /> .,,EI4TRALSERVICESICLERICALIPUB-SV.MKIWJSTER.PS04CROACHIASINT PERMT APPLICATIOH.DOC (09/73) <br />