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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: _ <br /> Date �- OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 7�O/ 7� REF.# <br /> Department of Public Works APN CR# <br /> - � _ EXP.DATE 1-(S <br /> C) I A `VV ,9►E2x2..Q' 0VALID f-2-.�—-157 _ TO 7-/,(S DRIVEWAYS: <br /> (Applicant Name) STREET Eld Ja AyAREA QUAD <br /> 1(D 0 R E QA F �/ 11�! t ST TYPE I l e s <br /> (Mailing Address) FORMS W 12)L- <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for ermissio excavate,cavate,construct andlor otherwise encroach on County Highway Rightof Wa on <br /> the N�r+h side of Tl n r i 0 e approximately y' � o2OQ ee mile <br /> of <br /> by performing the following work(description of world: <br /> r -1 <br /> c� l' )< <br /> Work will commence on or about fora proximately days. <br /> i,the undersigned,certify that!am the owner of the respective property,or m�ual f . 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 /> Oita"-)- -� 0„42 <br /> Signature of Applicant o Title I DP te <br /> tlt%MWMALSEWCEWLE21CAl1PDMWF'PMSTERnE-CROACHMENTPERA4fTAPPUCAnO0LDOC(0913) <br /> 1 <br />