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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Q <br /> Date i`J ) 0 �OFFICE USE ONLY <br /> To: San Joaquin County JOB# ���„�(3��� REF.# <br /> Department of Public Works APN CR# <br /> `,�� EXP.DATE <br /> (�lo! A Y V i�j�Q -(Z(� 1 -,E VALID 1. [� TO +Z-I, - 1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA <br /> 1 A 11 S- QUAD ES _ <br /> 0 � I S� TYPE S) <br /> (MailingAddress) FORMS WI ;� n�i,.� <br /> K-1 © N/ � 9 5t� NOTES <br /> (City,State,Zip Code) <br /> (Area t;ode�Teleph®ne�Irarrrber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encr9ach oniCounty Higi way Right-of-Way on <br /> the �� % t side of C, <br /> �'�,c� approximately �� fee mile <br /> of r�ti � (��• �t i <br /> by performing the following work(descri.ption of work): <br /> SfV �. <br /> Work will commence on or about ' i�- for ppr ximately .) <br /> days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualifed t represent the owner and agree to do the- <br /> val. <br /> Nf' f <br /> l 1 .� <br /> Signature of Applicant v Title - Date <br /> htICENTRAL%WCMUB'JC&)PUBSVWKV4kSTEPPSIENCROACHA1QdiPERM11RAPPUCAT10KDOO(09113) <br /> 1 <br />