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APPLICATION FOR ENCROACHMENT PERMITS AU" <br /> IS 2 5 Ai,i <br /> PLEASE PRINT: 8: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works V C'lc� REF# <br /> APN <br /> -------------- CR# <br /> EXP.DATE <br /> 4ALID <br /> (Applicant Name) STREET LL4:2--1>__ TO DRIVEWAYS: <br /> AREA QUAD <br /> TYPE <br /> (VIdIfIng Address) FORMS <br /> 2-n NOTES <br /> (City,State,Zip Woe) <br /> 2, <br /> (Area Code Telephone Number)Sketch(Detailed plans may be submitted) <br /> The undersigned, preby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right <br /> the side of <br /> of approximately of Way on <br /> ————————————— feet/mile <br /> by perfoaWing-the following work(description of work): <br /> Work will commence on or about <br /> — forapp�roximate�ly <br /> 1, the unqersigned,certifydays. <br /> th t I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work des ribed abOV in acc,rdance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br /> sign�i� <br /> .;, t T���� 4 <br /> J, r o Applicant-Title Date <br /> M:ICENTRALSERIACESICLER'CAL'P'JBSVWK141ASTERPSENCROACliMENT PEMITAPPLICAPON.Dc)c (09173) <br />