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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -9 — 2.d 1!� OFFICE USE ONLY <br /> To: San Joaquin County JOB#, 7124052y,' - REF# <br /> Department of Public Works APN CR# <br /> 6 a 21 EXP.DATE <br /> I L !/ �S <br /> VALID o; 0 DRIVEWAYS: <br /> �� �� <br /> (Applicant Name) STREET <br /> AREA QUADS } <br /> P� 4t® :_� TYPE t�iC.+st ►/ <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> ® 31 — 1 -77 <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 C—: side of approximately�q�n"_ Vef�e�'mile !!; _ <br /> of U th St 7"®c/c 7,p& by performing the following work(description of work): <br /> Work will commence on or about a — ;:z p p for approximately, /6 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 /> &-5-1- &rpti - $-/-3 - .-->-e 16;- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPU&SV WKIMASTER PSIENCROACHMENT PERMIT APPLICATION DOC(09113) <br />