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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ p a 6 2-61215 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works REF# <br /> APP CR# <br /> EXP.DATE p <br /> VALIDr <br /> (Applicant Name) STREET' Wry T,/ To 5 5' DRIVEWAYS: <br /> AREA �+i2----/=( — QUADS <br /> (Mailing Address) TYPE <br /> � � \ FORMS <br /> UJ 0'-)A <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> c.ar -La , I rr4-x;. <br /> The undersigned hereby applies forermission t excavate,const <br /> the side ofruct and/or otherwise encroach on County Highway Right-of--Way on <br /> _ r ' r'�- a c,�,��� <br /> Of approximately feet/mile <br /> ac,� I �� -, by performing the following work(description of <br /> Work will commence on or about )3 <br /> —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 /> U I <br /> ' lu�v'`` <br /> Signature o pplicant-Title ` <br /> Date <br /> M10EKrRAI5ERVICESICLER'C&WU&SV.YMIMASTER-PSIENCROAC"W PEFU.rTAPPLICATION.DOC(09/131 <br />