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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / 3 — 201!;— OFFICE USE ONLY <br /> To: San Joaquin County JOB# ;r 3005 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE: W/!57 <br /> /S <br /> 4 I p$A -3 VALID v / TO ItIl tS DRIVEWAYS: <br /> (Applicant Name) STREET !tiW3o� <br /> AREA 514!!AA? QUAD 65 <br /> q,c> q TYPE tP ,x/39,,¢ <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State, Zip Code) <br /> A10 -7t-137 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed 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 6t 1 A) U.2 i^Ndssr approximately feet/mile <br /> of C2g bo r n A Ve _, by performing the following work(description of work): <br /> Work will commence on or about =( - 01 S _for approximately /a & 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�r�� 1-3 <br /> Signature of Applicant-Title Date <br /> MICENTRALSERk�CESICLERICALIPU&SVWK1MASTER.PSIENCROACHMENTPERMdTAPPLICATION.COG(09113) <br />