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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 - 1 -9 - 2_e l!� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73005z_G REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /d r if <br /> 77 8 VALID o /13� T /t i tom- DRIVEWAYS: <br /> (Applicant Name) STREET0410 , <br /> AREA aGe�Z/1 QUAD <br /> °� TYPE <br /> (Mailing Address FORMS $ �c✓W` _ r1eA4A <br /> NOTES f 17 <br /> (City,State, Zip Code) <br /> 31 i� 774'7 <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 5-65-2- 6 bA r-t--�' approximately—a —)mile_�__ <br /> °f � =y`&u ®�f�'/�r�, by performing the following work(description of work): <br /> Work will commence on or about ___��.— .�d � ��/���- for approximately __,��_� <br /> 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 /> a — Pe r t"o'-1- 4 44ko as T, '* -/-3 – 16;– <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERIACESICLERICALIPUB-SU.WKIMASTERPSIENCROACIIMEidTPERMITAPPLICATIONDOC (09113) <br />