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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �_ Jl/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 3O0 SZ REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE -1-15 <br /> VALID 5-4-15 TO 9-1- 15 DRIVEWAYS: <br /> (Applicant Name) STREET p(zddS Ed <br /> � <br /> ` AREA o QUAD <br /> xg �K.]-Y5 C <br /> C5L_ PAsZ k �C C- TYPE <br /> (Mailing Address) FORMS <br /> ^ 2 � NOTES <br /> ( ity,State,Zip Code) <br /> ZD t <br /> -(Area Code-Telephone Number) <br /> J� S0 pqe• (d n <br /> Sketch(Detailed plans may be submitted) <br /> 3d4 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the�).S. side of approximately 106 <Mvmile tr 4ES' <br /> Of ___ `4 ,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 accord a with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sure o pplicant-Title Date <br /> tn <br /> E:+PUB-SV.WKIIAASTERPSLFNMOACNMENi PERMIT APRJCA710N.DOC(0110a) <br />