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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date y�� S� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7300 -5".>— REF# <br /> Department of Public Works APN CR# _ <br /> n EXP.DATE (-1 r <br /> aG TC. S S OleVALID D1 ,ZZ,1S' TO g,*"-/-I S DRIVEWAYS: <br /> (Applicant Name) STREET J��1,�y��a&(- <br /> ,J AREA QUAD <br /> 40 LO WhO L rl/ TYPE <br /> (Mailing Address) FORMS <;5 W <br /> �n oq NOTES <br /> (City,State,Zip Code) <br /> 1-10,-- 3/b- 170 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies r permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Q)av-It,. side of approximately-/JO f10f�'mile� <br /> of a �,r by rforming the f (lowing work(description of work): <br /> Work will commence on or about J vie. 1 k . Zo1 s for approximately 'Sa days. <br /> I, gure <br /> ,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> wove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 2 Pe <br /> of Applicant-Title -'-- Date <br /> MICENRALSERMCEMCLERICALIPU&SVWKIMASTERPSIENCROACHMENTPERMITAPPLICATION.DCC(09113) <br />