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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' 5 OFFICE USE ONLY <br /> 10: San Joaquin County JOB .7 REF# <br /> Department of Public Works APN CR# <br /> _ _ EXP.DATE <br /> I Q cL(�(�l Q (_ VALID - 5-- -1-1 S TO -1y DRIVEWAYS: <br /> (Applicant Name) STREET _ cooltdo A ` <br /> AREASfi� QUAD <br /> f` ST' TYPE P 1/ho P - <br /> (Flailing Address) FORMS 45 k/W k _ <br /> - �Td L K 1 ©N � q5a-0NOTES - - <br /> (CRY,State,Zip Code) <br /> a0�1 trey <br /> �—1(Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> thel 4 side of approximatelyof <br /> flee mile <br /> by performing the following work(description of work): <br /> /0 <br /> j nO <br /> Woric wi[I commence on or about I for approximately <br /> days. <br /> y <br /> 1,the undersigned,certify that 1 am the owner of the respective pro rty,or am alified to represent the owner and agree to dothe- <br /> workdescribed above in accordance with the rules and regulaiions of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant Title Dgfe <br /> FA:10E TRALSERMCESICLERICALV URSV.Wi L4ASTERPSIE-CROACHAtEt4TPER&IfT4pL1CAnoO L00C(09,13) <br />