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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ;' ' 23 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ 3 - I s <br /> U/J'1 VALID j _ Zy I,�? TO S DRIVEWAYS: <br /> (Applic/ant dame) STREET �- <br /> (1 �Il1I�L�O�'J�r f !` r TYPE SAREA QUAD _ <br /> -y- (Mailing Address) FORMS <br /> -NOTES <br /> (C -------- - ------ <br /> — �y,State,lip Code) - -- - <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �- Le- <br /> The undersigned hereby applies for permission to xcavate, struct and/or otherwise encroach gn County Highway Right-of-Way on <br /> the- rte, side o <br /> Of AV approximately <br /> feet/mile <br /> - by performin the following work(description of work): <br /> Worl<will commence on or about for approximately <br /> 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 desc ' �1bone in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature ofi Applicant-Title 2-3 <br /> D to <br /> IA.ICEN RALSERVICEMCLEiICAL1PU3SV.wh%%LASTERpS1ENCROACHMEtJTPERAfITAPPLICATION.DDC pjq <br /> I�<c; <br />