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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000 5� REF# <br /> Department of Public Works APN CR# <br /> _ _ EXP.DATE 1 t- 1 �4 <br /> b.� , 1 &Z'165ZCOQ i -L11r* VALID a TO t� �_ DRIVEWAYS: <br /> (Applicant Name) STREET O.J cv1b8f_z> Vr) , <br /> AREA '�' ,�-c,p� QUAD 5W <br /> � <br /> 6 WAN\ � TYPE I (`I VU► E. Q. oz> CLOSU2t,- <br /> (Mailing Address) FORMS 55 lawti 2 ZS -rre..c G,�}; A(��.� <br /> --- <br /> TZK3 D-) 2- - -NOTES — --- -- - <br /> (City,State,Zip Code) <br /> (Area Code o 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 approximately feet/mile <br /> of ,by performing the following work(description of work): <br /> U <br /> 5 A <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 kcdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant o Title Date <br /> M"CENTRALSERMCESlCLB'CAL1PUBSV.WKMASTEPPS�ACROACHMEMPEPhi]TAPPUCAnor4.00C(09173) <br />