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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / ? — 2.d/.S <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> �6, P EXP. DATE 11/1 ;- <br /> (q 7 VALID to , 0 rr t ! DRIVEWAYS: <br /> (Applicant Name) STREET i4juw. pr <br /> AREA �,,Q QUAD Irl$ <br /> �� ��® L����� ��al�� TYPE 11 +k It <f oft <br /> (Mailing Address) RMS 55&2Ljt Q'�; � �{� Ali <br /> NOTES <br /> C A q <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 excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the .S side of 2 3 1 t E S-r c t-44 approximately_ 4?77e�e�l?nile <br /> of by performing the following work(description of work): <br /> Work will commence on or about �.® �d ® �,®����- fora roxim <br /> PP Y 6 � 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 /> atel <br /> Signature of Applicant-Title Date <br /> M ICENTRAISERWESICIERICALIPUB-SVWKIMASTER.P&ENCROACHMENT PERMIT APPLICATION DOG (09113) <br />