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. j <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1130 ' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / ! <br /> __. VALID ,!d !a ! TO /2 ! I� DRIVEWAYS: <br /> (Applicant Name) STREET �l/Ic�/6uty �v. $e,We. <br /> til $1� AREA gSeALon! QUAD z: <br /> J + TYPE �.ry,P� �rrn/ 8e2i1-sem lgewrE <br /> (Mailing Address) FORMS_ <br /> NOTES �— <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 _side of approximately feet/mile <br /> of.�77 / / / by performing the follow/ing work(description of work): <br /> 13 c -// C W (�- /7VPU 1 4G'I tb�tely�� 44d�,hJah AnJ'c�. W.1 4 U LJMG1BrmC/Le��/rb <br /> Work will commence on or about for approximately' days. <br /> 1,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 /> .b E— <br /> Signature of Applicant-Title Date <br /> £`J'UZSV 4'nlV}g7�PF:CP.O:.(:F'.^{T PEFl7 RP7lJCATIC:I DOC[ii.il <br /> 1 <br />