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A APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ t f� OFFICE USE ONLY <br /> To: San Joaquin Countyll` , - JOB# -7 3190 s Z REF# <br /> Department of Public Works -J �! APN CR# <br /> - EXP.DATE <br /> TO 8,! -►S DRIVEWAYS: <br /> (Applicant Name) STREET H r!Dre fly Lh <br /> > ` � AREA �J(),etQ10 QUAD <br /> J 1 ; <br /> TYPE <br /> (Mailing Address)/ n FORMS t" S, Z !� <br /> c 7x" I J NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> I � <br /> The undersigned-hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the I _ =,t, t side of approximately feeNmile <br /> of by performing the following work(description of work): <br /> �. .: } <br /> Work will commence on or about for approximately l t days. <br /> I,the un ersi ned,certifyth t I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work des ribed abo e in cc,rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ign lur6 of Appficant-Title Date <br /> MICENIRAL5FWCESTC1-ERICAL'PUB SVWKIAIASIER.MENCROACNMENT PERMIT APPLICATION DOC 09113) <br />