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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date l o 'i ( i 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# gV3P 7O,by j( REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE ((-Z BZ�l <br /> I S U EST Fo 2 ��5 �v � VALID 1- TO DRIVEWAYS: <br /> (Applicant Name) STREET ` <br /> AREA UAD ` <br /> po ��x \5X12 TYPE -, V''�wcz <br /> (Mailing Address) FORMS U9 N40-6 <br /> NOTES <br /> 1✓ tic. C P, `1 23ta <br /> (City, State,Zip Code) <br /> Zcq ( X14-2 - 13UG <br /> (Area Code-Telephone Number) <br /> To�.ti 2o q I ieo3--s - <br /> Sketch(Detailed plans ma 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 approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about for approximately 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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> VipI <br /> 'gnature kf Applicant-Title Date <br /> M!CCITT-13-.111CIXL:RI-1III.---I.--Fl P-NCP.OP I.BT PE?MIT APPL'CATION.I. (09117) <br />