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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 Z— G/{' <br /> 1 VALID --20 1:5 DRIVEWAYS: <br /> (Appli nt Name) STREET <br /> AREA L`; QUAD j <br /> TYPE <br /> (Mailing Address) FORMS <br /> 63 NOTES3 <br /> (City,St te,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be subDmitted) <br /> se <br /> 0 rawknq —;e' 0'�Cw I kkor <br /> Low. of.e-p S. in Tiez�,r. <br /> Oe, wtl1 use, W" C-1t),5 , OL <br /> 'e- aL0U+A Ions, <br /> a� a� � iR� � Trey ) 530Y <br /> The unersigned hereby applies for ermission to xcav te,construct and/or otherwise encroach on County Highway Right-of-Way o <br /> the o si a of, a 1 approximately !300re mile LNi � �t <br /> of i oby performing t e [lowing work(description f work): <br /> s± CDa + e- a3 o #n 1»'w es �- <br /> Work will commence on or about — for approximately a 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date`( <br /> M;ICENTRALSERACESICLFRICALIPUB-SV.WKMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (09113) I <br />