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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ® d � � ��d�-5� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB#, 7300 z-- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE tE t j5" <br /> 11-57-5s 7 3 VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA ,� , " QUAD <br /> ��� �� �_4 TYPE l } �1 Gi�lr re a,r <br /> (Mailing Address) FORMS <br /> NOTES <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- <br /> the—S&TH sideof_ )S' fV D1.'V_&- approximately e mile � -Vay on <br /> of_ � s/� �� t,,A '5 r'2 by performing the following work ascription of work): <br /> Work wifl commence on or about_ �� w .� ��o�____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 /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLPRICALIPUBSV.WKIMASTER.PSIENCRoACNMENTPERMITAPPLICATIONDOC (09113) <br />