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—_ � 2���� wy� t l <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date %&LII OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3(� 52— # <br /> Department of Public Works APN CR# <br /> / D /Q t EXP.DATE 15' <br /> P6 Ve4 <br /> q VALID !Q'2-7-(* TO Z -1-ks DRIVEWAYS: <br /> 4(Ap`l�c�at Name) STREET , UAD IQ c <br /> AREAQ <br /> TYPE <br /> (Mailing Address) FORMS ��(�l�—� <br /> NOTES <br /> (City,State,Zip Code) <br /> 114- 7��-� � <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> y't-A <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/mlle <br /> of by performing the following work(d scription of work): <br /> C A <br /> Work will commence on or about t ( 1 — << for approximately j 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 /> i <br /> Signa a of Applicant-Title Date <br /> fd{CEtrTRALSEft110EMCtEMC6LWUB-SV,%MK;ASTERPSOICP.OACH1:EtfrPEfUdITAPPLICATk7tt000)0:113) <br />