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APPUCATION FOP ENCROACHMENT PERNT <br /> PLEASE PRINT: <br /> Date �!1Z /,5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# '` r? '_ REF# <br /> Department of Public Works APN — (I # <br /> y ' EXP.DATE q, <br /> J1 2( ' ` ) VALIDY E~ <br /> (Applicant Name) STREET O d / DRIVEWAYS: <br /> �31 <br /> AREA <br /> C-. ', QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> r c� NOTES <br /> (City,State,Zip Code) — -- –- <br /> (Area Cede a Telephone Wum ber) <br /> Sketch(Detailed plans maybe submitted) <br /> I <br /> I <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 side of <br /> of approximately feet/mile <br /> by performing the following work(description of work): <br /> Work will commence on or about, ' <br /> fora approximately <br /> y _ days. <br /> 1,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 accorda - ith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 61 <br /> Srgnaiure of Applicant e Title " — <br /> Date <br /> tdl'.,'EMRISERVICESCISZICAL1W35V.VJh'V.IASTER.p51ENCROACH;iBJT pFFd,!Ii APPLICAT70N.000(0113J <br /> 1 <br />