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/zvy-0� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# '7 3 Q()S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3 l S— IS <br /> P6, - C VALID p - -(� TO �3-[S _ DRIVEWAYS: <br /> (Applicant Name) STREET d <br /> AREA QUAD <br /> �',l--4- 7� PG(. TYPE _ <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �12� -2H`f •3��/ <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 feet/mile <br /> of ,by performing the following work(description of work): <br /> Gr s o os 'r R �ld <br /> r 62 <br /> Work will commence on or about_2 / /5 for approximately ,2/ 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* accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sign 'ure�of-XppIicant-Title tate <br /> hl'.CENTP<ALEER\�CES�CLERICALIPUESJ WHIA4AETER.PSIEIICRUACHI:IEWT PERIdR,NPLICFTIOIJ,DGC(09117) <br />