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PLEASE PRINT.- APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11 <br /> Department of Public Works APN - REF <br /> CR <br /> EXP.DATE <br /> It 0 15 <br /> (Applicant Name) <br /> VALID /,0 1 DRIVEWAYS: <br /> STREET r4 AV,TO <br /> AREA <br /> TYPE c"A QUAD <br /> (Mailing Address) FORMS eeofe M <br /> NOTES 40 '-e-1 <br /> (03f,State,Ldp Code) <br /> (Area Go—de Telephone—ft—m—ber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for f-W <br /> permission to excavate,construct and/or otherwise encroach on County Highway Right-of Way on <br /> -77 approximately <br /> feet/mile <br /> , <br /> by performing the following work(description of work): <br /> Work will commence on or about <br /> for approximately- days. <br /> 1, 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 irlspection and approval. <br /> Date <br /> &LICEtfTRALSERVICESIcLrRICAL,pUM,j WKI,.LAS1FRP80JCR0ACHW.eJT <br /> PERI/FrAPPL1GAT1014.130C P113) <br />