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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date// r OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> n �I� EXP.DATE _d-j <br /> i VALID yrs-i s /TO �-� -3 '(S DRIVEWAYS: <br /> (Applicant game) STREET ld(�td ! T t <br /> y Gyp �- I AREA QUAD <br /> !'� <br /> 5 5 <br /> �P� L dv TYPE <br /> (Mailing Address) FORMS <br /> q SZ oq NOTES <br /> (City,State,Zip Code) <br /> 6— 17(P7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ya L � <br /> The u ersiggned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the f- side of t aooc t �T approximately SL& -- <br /> of mile o� <br /> —, by performing the following work(description of work): <br /> 4 Caw 1!3 <br /> Work will commence on or about for approximately <br /> 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 a n accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> eKW-J C �11/1 <br /> i e of Applicant-Title rDate <br /> AI:ICENTRALSERVICESICLERICALIPUBSVIS'KNASTER.PSOICROACHtLEIVTPERP.I[rAPPLICATION.00C(013) <br />