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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date b OFFICE USE ONLY <br /> To: San Joaquin County JOB# " ' 'z-,� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> _ 7//,,0y0 kllC A) /L, <br /> VALID �,C : O `TO DRIVEWAYS: <br /> (Applicant dance) STREET <br /> y ro <br /> Wer, <br /> , er,f L AREATYPE T <br /> W S��fC QUAD <br /> (Mailing Address) FORMS(1114- <br /> NOTES <br /> (City,State, Zip Code) <br /> �- <br /> (Area Code-Telephone Dumber) <br /> Sketch(Detailed plans may be submitted) <br /> SC 4=7-`4u+6D S KIFTC-1-1 <br /> �M all I-72- <br /> d c jjbq50.S <br /> The undersigned hereby applies for perraiiss�ion to excavate,construct and/or otherwise encroach on County Highway Right-of Way on <br /> side of `9 approximate) S-];� r <br /> S�- y mile Wcs <br /> of ��C <br /> by performing the following work(description of work): <br /> r aNl <br /> Work will commence on or about <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 a ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signatur scant-Title <br /> Date <br /> ""EMRAI'ERACE"CLERICALIPU&SV.WKL'AAS1ER.PSIQICROACWEIVTPERMIIAPPLICATION.WC(013) <br />