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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 13 — 13 " 2®/!� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1-400 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> v 2 VALID ��," 0 r DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA a QUAD <br /> ® 410 Lest kip TYPE IWAQ <br /> (Mailing Address) FORMS <br /> NOTES <br /> A Q.6'-2� '/ <br /> (City, State, Zip Code) <br /> �i0e — 1 `7617 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> '4t-�aw <br /> The undersigned hereby applies for permission to excavate,construct an or otherwise encroach on County Highway Right-of-Way on <br /> the S --sideof 4d `'1( pproximately y 2`7 e�nile L0 <br /> of &�-{- ".. �o�lc 7� , by performing the following work(description of work): <br /> Work will commence on or about � :2 d s- 2 bt®e; for approximately d 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 /> 4�__ P�r��t '_a�pd,, t) 3 - �® 16;- <br /> Signature of Applicant-Title Date <br /> MICENTRALSERVICESICLERICALIPU6-SV WKWAS1ER.PSIENCROACHMENT PERMIT APPLICATION.000 (09113) <br />