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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — I _g — > OFFICE USE ONLY <br /> To: San Joaquin County JOB# 0,2- REF# <br /> Department of Public Works APN CR# <br /> -�-✓"- FYI 1) ! .2 er LB EXP.DATE # 31' - <br /> J VALID '" TO U , DRIVEWAYS: <br /> (Applicant Name) STREET �}"�,lI cr, <br /> AREA ��tJ QUAD k <br /> �! TYPE ELt. DlAiIA4tGK7i sR <br /> (Mailing Address) FORMS mow✓ � y� <br /> NOTES <br /> aA <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavat ,construct d/or otherwise encroach on County HighwayRight-of-Way on <br /> the r�prtk side of-- A-5 'ek L '- approximately 2 e � Esc <br /> ile�� <br /> of F r �i+� by performing the following work escription of work): <br /> Work will commence on or about s i 2 C? for approximately G1 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title <br /> Date <br /> M:ICENTRALSERVICCSICLERICALIPUR-SMKIMASTER.PSIENCROACHMENTPERf,11TAPPLICATIOfJ.DOG (09113) <br />