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APPUCATM FOR ENCROACHMENT PERMT <br /> PLEASE RIK. <br /> Date � <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB 1,30r�S2 -& REF# <br /> Department of Public Works <br /> APN CP# <br /> L EXP.DATE <br /> vALID r � ' To ,, �," DRIVEWAYS: <br /> (Applicant Marne) <br /> STREET N } <br /> z��� A <br /> AREA -� 0 QUAD <br /> Wailing Address) NFORMS <br /> OTES W4r--7 <br /> CAI <br /> (Cety,State,Zip Code) ®� <br /> (-Area C®de-9 eEephone iumerg <br /> SI<etch(Deiailed plans may be submitted) <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 <br /> of approximately feet/mile_ <br /> TZ2 go , by performing the following work(description of woriz): <br /> Work will commence on or about —A ® per <br /> for approximately days. <br /> 1, 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 /> --- -� a�� MA a Ce'45 redo <br /> Signature of Applicant-Tate ® 1 ;:1,o <br /> Date <br /> Af:tCCHiHgL:ERVICESCIERICALIPU&SV.4VNL:ASTER_PSIEIdCROAGHMEIdT PERIdfTAPpLICATiON.UOG (00.113) <br />