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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date In -'I z-f4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# C�§2,.S-REF# <br /> Department of Public Works APNCR# <br /> EXP,DATE <br /> C�"— -+ <br /> E2 F- VALID -20/ TO o--1•-2 DRIVEWAYS: <br /> (Applicant <br /> Name) STREET ap m'-szae ` <br /> t�.3 ��lL rtict2K. <br /> YLACC-- TYPE <br /> E QUAD _ <br /> t <br /> (Mailing Address) FORMS (�Q�`[ye� <br /> 2 NOTES <br /> ( ity,State,Zip Code) C� <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 `C16 d /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 accord n e with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> j Si n 'Lire o pplicant-Title ^ Date <br /> EL-L1 V.WKU4AMERPS81CROAOUEMPEHAItf APRJCATION DCC(0708) <br />