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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County--- JOB# (� 2 REF# <br /> Department of Public Works APN CR# <br /> EXP,D <br /> ATE <br /> VALID TO RIVEWAYS: <br /> (Applicant Name) STREET a ^J!— �)— di <br /> � <br /> AREA ���^ QUADQ/'� TYPE "e ' <br /> (Mailing Address) FORMS �! <br /> q� 7 Z o NOTES <br /> (Ciy,State,Zip Code) <br /> 317 s 73 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,con t c %1or otherwise encroach on County Highway Right-of-Way on <br /> the fiside of l gwAe pproximately feet/mile <br /> ofscrl 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> �,yrq�vl` Z Z 3 <br /> Signature ofApplicant-Title Date o <br /> E..IVSSVWMOSTERPSZNCROACHMEHIPER APPLICATICN.DOC(01M) C) <br /> V <br />