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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB <br /> 'Department of Public Works APN REF <br /> EXP.DATE CR# <br /> VALID— 5- <br /> (Applicant Name—) STREETA 0 15' DRIVEWAYS: <br /> Ale-- <br /> AREA c QUAD <br /> TYPE 44y,�M�lc <br /> —Mailing Address)— �oe~4�pe D-r) <br /> FORMS <br /> NOTES <br /> (wtyy,State,LIP(;Ode) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed Plans may be submitted) <br /> ?41 <br /> Sketch(Detailed <br /> The undersigned hereby applies for permission to <br /> the excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> of side of 1-, <br /> approximately <br /> by Performing the <br /> k <br /> T0-110W�ingwork(description of work): <br /> Work will commence on or about <br /> —foraPProximately., <br /> 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 ins <br /> p <br /> ection and approval. <br /> t <br /> Signature-of-A-p—plEa-6t Title <br /> Elate <br /> &LIC;Et[FRALSFRUCESICLEpirALU,UMVIVK["IASTEP'PS'2'CROACW,EIIT,,P,,,,,AP.,ICAnomoDC PTO) <br />