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APPLICATION FOR E:NCROACI4MENT PERMIT <br /> PLEASE PRINT: <br /> Date Zp .l j <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# / 000 REF.# <br /> Department of Public Works APN CR_# <br /> EXP.DATE <br /> f U ku o rl-E��,c-� v..� `1�1C, VALID —T— <br /> (Applicant Na ne) STREET — TO 7-l -(S' DRIVEWAYS: <br /> � O- &aX TYPE T QUAD E <br /> (Flailing Address) / FORMS SSW W 5 <br /> NOTES <br /> (City,State`,Zip-Code) <br /> (Area <br /> - —- <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed pians may be submitted) <br /> �-�- �Kid <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 <br /> of approximately feet/mile <br /> o by performing the following work(description of work): <br /> 5o Ji s `c a. J <br /> Work will commence on or about for approximately �, 20 —days. <br /> 1,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 describ above in accordance h the rules and regulations of San Joaquin Cou4subjecttoinspection and approval. <br /> ignature of Applicant Title <br /> N,9CEFt ISEWCESlCLERICAL\PUMV.Wl.3F.7ASTLRPSkaCROACHYEtTTPE-%i[TAppUCATION.COC (09113) <br /> 1 <br />