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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / .a — OFFICE USE ONLY <br /> To: San Joaquin County JOB# oo5�-C� REF# <br /> Department of Public Works APN CR# <br /> �1 Q EXP.DATE !, <br /> VALID 1,0/1115' 0 /f t ,S" DRIVEWAYS: <br /> (Applicant Name) STREET 57: 11 1 <br /> AREA -�ae.C"I A QUAD -5S <br /> 41® toe�,_4 (—a TYPE <br /> (Mailing Address) FORMSt„kty -L�, <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-Way on <br /> the !!5 side of D 3 77 '-7 L� approximately L e ile �_ <br /> of ( _�t " -� by performing the following work escription of work): <br /> Work will commence on or about rJ ;;:z p/,C- for approximately 9 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 /> —4Signature of Applicant-Title Date <br /> M:ICENTRAL9ERVICESICLERICALIPU6-SV.Wl.M TERPSIENCROACNMENTPERMITAPPLICATIONOOC X09113) <br />