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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 4 Date p�r1 ' <br /> j r OFFICE USE ONLY <br /> To: San Joaquin Cou JOB# ��y() 7 REF.# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 3.—I -I S <br /> I A �I�F�c )Es__U 1 Q,E VALID �_Z_15_ TO z� , 'r _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAQUAD <br /> !Q O 2 E . Q9 F ' E-r•E S—T" TYPE <br /> C (lWailing Address) FORMS FORMS <br /> ,JT L K-1 ON (—'A 9NOTES <br /> (City,State,Zip Code) <br /> 6)'Q ki 1, V -�13 I � <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Hi hway Right-of-,Way on <br /> the.�,v�+ side of I 5 approximate! <br /> of , Y ___?zCZ fee/mile�_ <br /> 0�s LR by performing the following work(description of work): <br /> AA � . <br /> � . <br /> Work will commence on or about t f r approximately <br /> days. <br /> I,the undersigned,certify that 1 am the owner of the respective property,or am qua fled fo 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 /> Si nature of ) 15 <br /> Sig Applicant�Title ate - <br /> M:10EN'RALSERNCMCLER'CACIPURSV.WKVJASTERP51ENCROACHA7EH7PERhIRAPPLICAT10ND0C(09113) <br />