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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: dU C�— 576LI' G 7 ) q <br /> Date f < <( OFFICE USE ONLY <br /> To: San Joaquin County JOB# ((cCy)"3-- REF# <br /> Department of Public Works APN CR# <br /> ,�— EXP.DATE /Z /.¢ <br /> �C(Applicant��� 1 Y1 VALID / TO /2 � q DRIVEWAYS: <br /> STREET <br /> AREA <br /> TYPE (ytb+Gu4i« Seek ASA <br /> (bailingAddress) FORMS ss]wu), Cw-�1 Cw-C <br /> NOTES <br /> A^ ele <br /> (City,Stage,2V Code) <br /> (Area Code o Telephone Number) <br /> Sketch(Detailed plans may be submitted <br /> See <br /> The undersigrkqd hereby applies for perms n to excavate co tract andlor otherwise encroach on County Highway Right-of-way n <br /> the JL4 side of I,.1S �' approximately O0 ee miles <br /> of , by performing the following work esc' tion ofor{cl <br /> Ilk <br /> i 14 <br /> Work will commence on or about for approximately /D 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 a ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si nate licai�t Title <br /> 9 l� Date <br /> MiCENTRALSEFMCESCLEICALNPUB-SV.WKVAASTERPSIENCROACNA1E17f PEkl1RAPPLICATIONAOC(OJ13) 1 <br />