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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 -g — OFFICE USE ONLY <br /> To: San Joaquin County JOB# J 7_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> P� rte �� 3 j ��1 6�'� VALID (o € t �_ �t r1) DRIVEWAYS: <br /> (Applicant Name) STREET 4e, ,4j . <br /> AREA 01 QUAD 155 <br /> ! TYPE <br /> (Mailing Address) FORMS <br /> NOTES j <br /> (City, State,Zip Code) <br /> 1 - 7 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,cogqstruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 6 side of d, AV (573--971 J approximately 2 s> nile U0 <br /> Of C Gt Y' '� _ _v �"®�`� � by performing the following work(description of work): <br /> Work will commence on or about �9— -2-Q. �11�7--._for approximately_ 'n 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 /> &r�moj- �a���n� � 9 -/-3 — ze16— <br /> Signature of Applicant-Title Date <br /> MICENTRAISERVICESICLERICALIPU&SV.WNIMASTER.PSIEPICROACHMENTPERMITAPPLICATION.000 (09113), <br />