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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> �-OU4- <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 10 005- REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> 11 CLI - I! f? VALID z-13-t 5 TO -/ - 5 DRIVEWAYS: <br /> (Applicant NM-e) STREET 1I?J <br /> � <br /> AREA QUAD QUAD A�5_ <br /> IPL �c)x l7 3 TYPE 1t L (nmfrol <br /> (Mailing Address) FORMS 5514114/ <br /> rmmU n . OA . g5S3D NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to a cavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the �� side of_ ' �t�N- � G1�, approximately X00 eet/ ile <br /> of by performing the following work( esenpi tion of work): <br /> Work will commence on or about TLS ;2, -110 157 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 Applican - tle Date <br /> M:ICENTRALSERVICES\CLERICAL\PUB-SV.WKWASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />