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rMAR <br /> 17 2Q{� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> By <br /> --ftd— <br /> Date OFFfCE USE ONLY <br /> To: San Joaquin County JOB# �— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> C57-> VALID 4-zz"I S TO DRIVEWAYS: <br /> (Applicant Name) STREET 5 /� <br /> ,-- AREA E•scu(U�j QUAD �� <br /> ter!' ��- TYPE AoV t? <br /> (Mailing Address) FORMS S ' � <br /> 2— <br /> NOTES _ <br /> (Ci),State,Zip Code) <br /> /'-� ) -31`7- 5-z� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed s may be submitted) <br /> The leo"I"In <br /> red hereby applies for permission o excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side ofi approximately �i5'� mile <br /> of , by performing the following work(description of work): <br /> Work will commence on or about for approximately 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 /> Az'z <br /> ign of A t-Title hate <br /> EtG13SV.VMAASrt PSLCNC.4W:MMEVT?LPJARAPPLJCATbN.DOC{OtAa) <br />