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P"-w�3& ll <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOS# "�3�d 5-� REF# <br /> Department of Public Worsts APN CR# <br /> EXP.DATE ( S - - <br /> VALID -I TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD c _ x <br /> TYPE rp <br /> (Mailing Address) FORMS vR-7 <br /> NOTES <br /> 4�C•�� (City,State,/Zip Code) <br /> 11/& 1/9 . 9 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highww Right-of Way.on <br /> the i1 t��' �z side of f�G;/% * approximately -2 �feetAnile �5c�a 7 f� <br /> of /3oN iSG_itivQ ',t? s ,by performing the following work(description of work): <br /> e f o�O 3 o Ile r-A <br /> Work will commence on or about — // 2 /:5 for approximately / days. <br /> a <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 /> Signature of Applicant-Title Me <br /> u�mvusem,cFsn�rcxResvwxwsreta�xxin�aeirtv�vTR�auna+ooc�3E <br />