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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / y f d oj2 <br /> Date /0%/�/ I OFFICE USE ONLY , <br /> To: San Joaquin County JOB# j 0005 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID Z40 5 TO 3DRIVEWAYS: <br /> (Applicant Name) AREA <br /> 1l.-:Y9A�t <br /> po- Qom. goy QUAD ; <br /> TYPE <br /> (Mailing Address) FORMS <br /> eA qr,7L/ NOTES <br /> (City,State,Zip Code)v(� <br /> X09 99� /6FZ <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 /> 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> MICENIRALSEPNCESCIEFIGal1W65V.W1Nl�5fERP5FMLROJLIBAENTPERAiR VPICAiIpi00L(W3,, .. <br /> ' j' <br />