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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 o l --> — 2 e OFFICE USE ONLY <br /> To: San Joaquin County JOB# 05 1 REF# <br /> Department of Public Works APN CR# <br /> P.DDATE <br /> VALID <br /> A <br /> (Applicant Name) ! TO !t DRIVEWAYS: <br /> STREET <br /> AREA g� ,A) QUAD fS <br /> ��� �4 L��t�. TYPE f ,�YAi `, E �� <br /> (Mailing Address) FORMS , 2,5rje tcA ® � <br /> NOTES <br /> A <br /> (City, State, Zip Code) <br /> A®e <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct an /or otherwise encroach on County Highway Right-of-Way on <br /> the [: side of /U (�(91���r Ave (- qz Li�pproximately... ;Z , _ e mile <br /> Of... r A ,� Stae !!t&p) , by performing the following worQUescription of work): <br /> Work will commence on or about for approximately ! 2 O 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 /> �-�,�� P�rte►�� ���r��� � ��-r.� a �� o�.� <br /> Signature of Applicant-Title Date <br /> MICENTRALSERVICESICI.ERICALIPUB-SUWKIMASIER.PSIENCROACHMENTPERMITAPPLICATIONDOC(M2) <br />