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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / _g 9 d l!� OFFICE USE ONLY <br /> To: San Joaquin County JOB 3W5-2,4- REF# <br /> Department of Public Works APN CR# <br /> 2 3S(� VALID 1 <br /> EXP <br /> ATE .- <br /> ' �" �` �- DRIVEWAYS: <br /> (Applicant Name) STREET �+�t)Est1l` Acte <br /> AREA %dL-16,D QUAD <br /> 4t� U2e'4 TYPE < 16kc t�0.�lQ1Anw Qa of % <br /> (Mailing Address) FORMSd,tc, <br /> NOTES <br /> (City, State, Zip Code) <br /> �18�® 31�- P 7,7 <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 E side of—573 !_Al _t,(; approximately feet/mile <br /> of- rz°=fA4 bel t 5;'C _5722t*4c ), by performing the following work(description of work): <br /> Work will commence on or about �9— .2d — �4',1S- for approximately /_':�zo 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 Date <br /> MICENTP,ILSERVICESICLERICALIPURSVWKIhiASTERPSIENCROACHMENTPERMI'r APPLICATION.000 (09113) <br />