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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date )Q 4-':d ':3- I .11iOFFICE USE ONLY <br /> To: San Joaquin County JOB# 30 � ? — REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> C LQ I T L-) N I A i�� ��(�(�j Q [ VALID TO _ (_� DRIVEWAYS: <br /> (Applicant Nadae) STREET <br /> )-..A F)9 E TT r~ r,-,-T' AREA <br /> TYPEifti�� <br /> QUAD _ <br /> (Flailing Address) FORMS f �q <br /> NOTES <br /> (City,State,zip Code) <br /> 1, y <br /> ��(Area Code a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for pgrmissioon�to excavate,construct andlor otherwise encroach on County Hi hwa Right-of-wayon <br /> -1- <br /> the LL2-(- side of approximatelyfee mile 5-o <br /> of W by performing the following work( escription of work): <br /> � OY1 <br /> 12 11y) <br /> fy--J- 0 <br /> Wont will commence on or about f� r approximately__ to days. <br /> I,the undersigned,certify that t 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 /> Signature of Applicant e Title I Date <br /> M:ICENIRALSERVICESICLERICAL\PUB-SV.WKVAASTERPSIENCROACHAIEIUPERMfrAPPLICA7IONDOC(09113) <br /> 1 <br />