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2- 9 4-,'-'�lLr <br /> Loc, I APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: C' T� � D <br /> Date — Z - 2o <br /> Z — I OFFICE USE ONLY ! <br /> To: San Joaquin County JOB# -7 ,0052— REF# <br /> Department of Public Works APN CR# <br /> �;A EXP.DATE: <br /> VALID -6 I_5-- TO _-1-15 DRIVEWAYS: <br /> (Applicant Name) STREET 1-0 <br /> AREA t-in (m— QUAD _ <br /> tea- YPE 13pre <br /> (Mailing Address) FORMS 4 / �Z-c! <br /> �a-L T S ���fU NOTES <br /> (City,SCate,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feeUmile <br /> of _ by performing the following work(description of work): <br /> U <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 ove in acc Adan with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> per\ S. <br /> Sign e o A lica t Title Date <br /> !,l'CENTRALSER`ACEF,CI.ERICAL`PUB SVWRlF.AASTERPSENCROACRMENTPM,',]T APPLICATION.DOC (DYItT) <br />