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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -g 9 &1/!;— <br /> FAREA <br /> CE USE ONLY <br /> To: San Joaquin County <br /> Department of Public WorksREF# <br /> CR# <br /> �1 O /� , 1; DRIVEWAYS: <br /> (Applicant Name)4lo AD t <br /> TYPE a e <br /> (,Cox;.r <br /> (Mailing Address) FORMS ��� � j • ���, <br /> NOTES <br /> (City, State,Zip Code) <br /> �l40e -31i;— 1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> thee undersigned hereby applies for permission to excav te,co struct and/or otherwise encroach on County Highw Right-of-Way on <br /> side of_ & - <br /> of- M u,r--�(p approximately 3 6'7 ee ile <br /> &'ro>,4, by performing the following work( escription of work): <br /> Worl<will commence on or about_ �� �e,1 <br /> for approximately ��� 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-Tetle I <br /> Date <br /> td.ICENTRALSf_RUICESICLERICALIPU6-SU.WKUdASTER.PSIENCROACHNENTPERMITAPPLICATIOtJ00C (09113) <br />