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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��1 /�S� OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3��52-C4, REF# <br /> Department of Public Works APN <br /> CR <br /> EXP.DATE t <br /> VALID TO 2 t / DRIVEWAYS: <br /> (Ap�ppiCarst 6elar¢ae) STREET WE33 �1. <br /> Ll6 LI U 1/lel L /'{� AREA Tac l,�'rrok QUAD <br /> TYPE 6>E.LL o t <br /> (Mailing Address) FORMS ncl <br /> NOTES <br /> `2 r' L--'-'� <br /> (City,State,Zip Code) <br /> 3/- -/ 7 6? <br /> (Area Code-Telephone Number) <br /> S{<etch (Defiailed plans may be submitfed) <br /> 5K <br /> The undersigned hereby applies for permission to excway Right-of-Way side of y <br /> avate, construct and/or otherwise encroach on County Highon <br /> (��.��j Sir' <br /> U1.` ' i f �� ap�}y � w*-��. feet/mile <br /> xe `` �_ 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 /> wor!<described accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si pip Heart-Title <br /> Date <br /> GlICE1TTRALSERIACESCLERICAf.IPUB-SV�%Kt!'ASTER PS ICROACKMENT PERrTAPPUCAT1014.[]0C (09113) <br />