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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLFASE PRINT: _ f <br /> Date l <br /> I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 720t - {g REF# <br /> fJ Department of Public Works APN <br /> �1� ��i{'l� �•--- VADP.DATE 2 r !w CR# <br /> (Applicant Name) STREET DRIVEWAYS; <br /> rc� <br /> C� <br /> �/IGf.�^� j • AREA -r"Ctl QUAD 500 <br /> t1 �{ ..�f " t3,% TYPE "C�iw� �{�i <br /> (Mailing Address) FORMS r0'Ce'�• <br /> �e .�C..+'>��,,.c..+��-�} t,�l'"�. �� � NOTES <br /> {City,State, ip Code) <br /> l� 0 - 5-3 C�-5 <br /> Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The u dersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ---side of-tom'--- I e- 5-71. <br /> of • L �.. ,- approximately. 3 d ( Jmile- <br /> - by performing the following work(description of work): <br /> Work will commence on <br /> 6 I V!for approxima#ely / days <br /> 1,the undersigned,certify that I am the ovdner 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 /> Signature of Applicant- a e <br /> Dat <br /> E:l UBSV.Y1iN.AST£R,PSL'-DICROACli;EItFPEA6ti7APFLICA71pN.DOC(01N3J <br />