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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / — 2-el-5, OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7goasz-Ga REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE !0 P y <br /> g Ts VALID v 1 0 �! ,�' DRIVEWAYS: <br /> (Applicant Name) STREET n eos Av--- <br /> AREA S�o�.lef'art QUAD ,ES <br /> Ql TYPE Tie 61 Naje C werten� f ,r <br /> (Mailing Address) FORMS 5 , 4.� � T"<e� �u11�uk� <br /> NOTES <br /> C A q -2� t./ <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> SI<etch (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 S approximately e mile_!_ <br /> of �� 2"®r.,k-to A2, by performing the following workescription of work): <br /> I <br /> Work will commence on or about _ :::z,1,1!g 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> MICENTRALSERUICESICLERICALIPUBSVWKWASTER PSIENCROACHMENT PERMIT APPLICATIONDOC(09113) <br />