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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date —( — 0 C i.5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( (000S REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 7-1S -/S <br /> 'l.<J�li l.� -I-nGC.�ts-tyl�S; L, VALID � -2.-�s' TO 7- 15-15 DRIVEWAYS: <br /> (Applicant Name) STREET P,obp,-ij 4 No * <br /> AREA V�tu ft� QUAD l <br /> l Q .`? f` = fZ%( l�h gJV-et TYPE eone <br /> (Mailing Address) FORMS A/tjl 2,-� <br /> NOTES 6L It ('A - 6 .(1- <br /> (City, State, Zip Code) <br /> (; 1 - 7yq - Fy�3 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately _feet/mile <br /> of by performing the following work(de cription of work): <br /> lie ull\ru CP <br /> all S;�JA <br /> D „r <br /> f r iso 1 <br /> IN <br /> Work will commence on or about r ' 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 /> ignature of Applic -Title `J Date <br /> M ICENTRAI SERVICEMCLEP.ICALIPUB-SV WNIMASTER PSIENCROACHPAENT PERMIT APPLICATION DOC (09113 <br />