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APPLICATION FOR ENCROACHMENT-PERMIT <br /> PLEASE PRINT: <br /> Date \` A\-:�;� !L� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 3p 2--1 REF# <br /> Department of Public Works APN y CR# <br /> �j EXP.DATE sS-I 241 <br /> C VALID 2--(2 TO -1-Z DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD " <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �-e -� U u - l q--] <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The u 0.dersigned hereby applies�fQQr permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of !- QS .A YZ-- appraximatefy 1.11' -feet/mile <br /> -sf' i,.l¢ C\ne(tom Q �. '[�eMv.,.� 9-d ,by performing the following work(description of work): <br /> AJ <br /> Work will commence on or about for approximately days. <br /> 1,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 de 'b d above n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> N� r-T) <br /> -- 1'� Iazd t <br /> Signature of Applicant-Title Date <br /> ................_............:.................:..._.:...:.....................:........_.........._............................._............_._........................................................_...................................................._.:.............................................................................. ... <br /> .......... ..... ... . <br /> LtiCF1RRPJ.SER1�Sd.1.ER'CILFVBSYritIV.ISTFRPSDKRa.CF:IEIRPERlhT/FPLKA7pt1000 hpJ13j <br />