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APPLICATION FOR,ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _�7/ 1 // S OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z Z 1 REF# <br /> Department of Public Worlts APN CR# <br /> EXP.DATE 1 S <br /> 1 Cl`0-5 VALID <br /> (APlalicant Name) STREET TO ��/`/ DRIVEWAYS: <br /> ✓'t <br /> AREA — Q - <br /> TYPE ; <br /> (�(MaalingAddress) r-oRMs <br /> NOTES <br /> (City,State,Zip Code) <br /> {Arca Cads�Tel2phorre Numk�Er) <br /> Sketch(Detailed p(ans Tay be submitted) <br /> sem <br /> e <br /> The`ude 'gned hereby applies r pe mission to ex avate,construct and/or otherwise encroach on County Highway Right-of Way on <br /> the `^' side of <br /> of ewer' '�`' approximately_`,()o % feet/mile <br /> 6y performing the following work(descript'on of work): <br /> e, V\ l << <br /> � fe <br /> !- <br /> t>D\Q <br /> Worlt will commence on ora t 7 _for approximately <br /> ----_7 days. <br /> I,the undersigned,cerfify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> Mdesc0edabove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> A r <br /> Signa re of Applicant-1 We <br /> ate <br /> UACEWrrwsEmnCE=BzMVU_V.1%1"ASTM PSGeAaCJENTrfw.o NftCarMDOC ro11y <br />