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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> —1 San Joaquin County JOB# _7�DO 7 7 REF'# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10-3 ( - <br /> )9 I'EP—snE 1_ ) )Q E VALID TO lD - (-( ¢ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAAd--too QUAD <br /> 1(0() E J.A r M i/ E T-1 •(-- ST ' <br /> 1" TYPE 84thn l A <br /> (Mailing Address) FORMS .- <br /> NOTES <br /> - moi aCYLT0 N O-A 95 <br /> (City,State,Zip Code) <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 /> side of approximately_1 fee mile Ltv-o� <br /> of o' " `L"a ,by performing the following work( escription of work): <br /> IL1000 <br /> Work will commence on or about f r approximately r� days. <br /> I,the undersigned,certify that I am the owner of the respective property,or 8irm 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 /> Signature of Applicant a Title rDa e <br /> 4A:1CEN(RALSERVICESlCLEPJCALIPU&SVWKVdASTEp-ps ETCROACHS7ER4TPERAIRAPP CATIOR00C(,Iq <br />