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1 <br /> Q � <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 71 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z.- L <br /> PGS VALID 1D-3(- tl TO _ _ ¢ DRIVEWAYS: <br /> (Applicant Name) STREETS S f <br /> AREA f-►h/II.QQUAD 4z C- - <br /> 1A.i��. IG(C (� TYPE 6or(? <br /> (Mailing Aaoress) FORMS 4s /W '0I <br /> NOTES <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 /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> PaL10- <br /> Work will commence on or about for approximately days. <br /> I,the ndersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work Jescribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> FL,q-i M^TpQ, -7• q- <br /> t Title �, Date <br /> MICENiRALSERVICESICLERICALIPUB-SV.WKUAASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (09113) <br />