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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 3 — OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE t t 1 5'"' <br /> em 3 11�l "l D VALID Ip 4 0 Ii t DRIVEWAYS: <br /> (Applicant Name) STREET , <br /> AREA "�c�t�, QUAD E x <br /> �� TYPE <br /> (Mailing Address) NFORMS <br /> OTES <br /> I <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 ) 12 A) ,a��p 17—approximately-.. . _�I'7 /Qmile _ ,! <br /> of_ t�t9 by performing the following work description of work): <br /> Work will commence on or about �� �� ®� for approximately days. <br /> 1,the undersigned, certify that I am the owner of the respective properly,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-Title Date <br /> M]CENIRALSERMCESICLERICALIPUB-SVWKGdASTER PSIENCROACHMENTPERMI(APPLICATIONDOG (MQ) <br />