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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 7 Q ) Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 16 -31-1 <br /> VALID <br /> (Applicant Name) STREET -1 S TO Q -?, f-!�' DRIVEWAYS: <br /> po wf A/ <br /> AREA >TI- �,I��rl� QUAD — <br /> TYPE <br /> (Mailing Address) FORMS <br /> 9 SZ 6� NOTES <br /> (City,State,Zip Code) <br /> lo— 17 G7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S <br /> 7T !q C I+T S CTG <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of Z� ,–i{c <br /> of approximately $S6 eet/mile�au4-� <br /> Vt <br /> —� , b <br /> S y performing the following work(description of work): <br /> VZ V S <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 /> e r wu°�- i s � //5 <br /> e of Applicant-Title Date <br /> ldlCENrRAL'EWCESICLERICALIPUMV.V�KUMSTER.PMENCROACHILENTPEIUARAPPLICATIONDOC(03113) <br />