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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> vsc, 'Fa i;—. S VALID TO DRIVEWAYS: <br /> (Applic t Name) STREET �� ,�, Ad <br /> r, r- AREA b n�y QUAD <br /> CF,:A h I I H �� TYPE RnrP <br /> (Mailing Address) FORMS S YI� 22 <br /> NOTES <br /> (City,State,Zip Code) <br /> Zv q-- (0 3 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The u,r��dersigned hereby applies for,permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ,r3G th side of /��h •/ "G /�o� . approximately f.5'3 feet/mile % s.� <br /> of ,T�< <t�.r AJby performing the following work(description of work): <br /> Work will commence on or about 'a Mo.,,ILFC for approximately ;may s 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 d ribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> r <br /> 'K ._6 <br /> Signature of Ap ant-Title Date <br /> Y(FORMS&TEEMPPLATESENCROACHMENT PERMIT APPLICATION.dx(08108) <br /> PPIA116 <br />