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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� ,� ao 1 -- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 M 0 7 7 REF# <br /> Department of Public Works APN CR# <br /> `,� _ EXP.DATE 6 -15'-1� <br /> V V �►'EJ (�.U)Q,[ VALID A _ _ TO g -(5-15 DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> 1 <br /> _ AREA - QUAD_Co 0 R E �A r���� E-FT f' S-T' TYPE <br /> (Bailing Address) FORMS <br /> -NOTES <br /> (City,State,Zip Code) <br /> ao�1to L/ <br /> (Area Code e Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for pe fission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of �cl ���9 approximately fee mileN��h <br /> of by performing the following work(description of work): <br /> Work will commence on or about for proximately days. <br /> s�� r s <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualii d 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 /> LA_ <br /> Signature of Applicant o Title pate t 5 <br /> FA:1CEWMSSUC:ESCLEPJCALVUBSV.WKV'ASTERI'SG\'CROACHA1EIWPE liTAPPLICAnOtiDOC(09113) , <br />