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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I ?, ?el!S OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> � EXP.DATE ! / <br /> 7 VALID t50 �_ <br /> p® � / _ _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA �11 QUAD R <br /> ® ���— " TYPE �%llllo <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> 177 : <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 Lc> sideofc, y f5 77Y4 S't` approximately __ ��if �#'/mile_.,_._ <br /> of— s — �o� �' by performing the following work(description of wor{c): <br /> Work will commence on or about A3 .:w s ;;;z ey!�-- _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 /> 4 -� 9-/-3 - :z e 1,5- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPU&SV.WKWASTER.PSIENCROACNMENTPERMITAPPI.ICATIOIJ000(09113) <br />