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3,2 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 A :�ih j OFFICE USE ONLY <br /> To: San Joaquin County JOB# qPLN7nV?3Ct(7--.'�'REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �5 VALID (177 <br /> - TO DRIVEWAYS: <br /> (Applicant Name) STREET & � I <br /> AREA QUAQ S` <br /> TYPE _ <br /> (Mailing Address) FORMS <br /> d NOTES <br /> (City,State,Zip Code) <br /> y7- 5-29 3 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The un rsi ned hereby applies for permission to excavate,c nstruct an otherwise encroach on County Highway Ri ht-of-Wayon� <br /> the . ✓oma side of P approximately �, feet/ le <br /> of sr�rbh — �� c by performing the following work(descrip ion 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> nature of Applicant-Title ate <br /> E+PVBSVWMM&STERPSTNL'ROACHME4TPMWAPPUCATLW.DOC(DIMS) r <- <br /> v <br /> e <br />