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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6%/ ,v f/�-� OFFICE USE ONLY <br /> To: San Joaquin County JOB# -1 SZ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID -Zt 1 TO1.4_>l /< DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> %ls�Jts ffllr'`�F Lc �� a TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> q ek 516 I -76,J <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) r� es,(c V) <br /> F[(-)((-Ir ifrf l �s r Itj/ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the me.,t t , side of approximately __ / S l ( ttmile r t- <br /> of. f,110 ,by performing the following work(description of work): <br /> Work will commence on or about !1 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 describe in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> re of Applicant-Title Date <br /> MICENTRALSERMCE9CLEPJCALWUMV.WKIMgSTERPS04CROACHMENTPERMRAPPUCAT10N.00C(O913) <br />