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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _Sr/11 // S OFFICE USE ONLY <br /> To: San Joaquin County rAREA <br /> X30O Z REF# <br /> Department of Public Works <br /> CR# <br /> E �Z <br /> (Applicant Name) <br /> STREET <br /> --� TO - /-( DRIVEWAYS: <br /> 1J6g0 �P UAD _ <br /> (Malting Address) FORMS Stkd <br /> rH <br /> ay NOTES <br /> (City,State,Ylp Code) <br /> 17 G-7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 14243 7432 <br /> Theersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 0v*4% side of.. 4�4x,, -4- A%J e <br /> of lAv- app roximately 5 ee�rnile�� <br /> V A�ol— �k�+� by performing the followingwork(description of work): <br /> Work will commence on or about <br /> _for approximately ndays. <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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> I e of Applicant-Title <br /> Date <br /> ht10ENTRA"ERVICESCLE"CALIPUBSV.E'KLMASTERPS1Eh'CROACHV.BTPERIdRAPPLICATIONDOC(09113) <br />