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APPLICATION FOR'ENCROACHMENT PERMIT <br /> PLEASE PRINT: - - <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7�(1 U 5-Z REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> VALID J (- rf-j s TO Z-( - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> /2/ Tao i -cam eGw` O-"L r2d• TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> CJ9 s 8-3 <br /> (City,State,Zip Code) <br /> 925 -zqq 3�1/ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> —r—C,n <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the Ea- E side of P tica•MA )Zd• approximately U d u fee ile <br /> of w 8 _,by performing the following work escription of work): <br /> I- <br /> - e filo f rPt n <br /> Work will commence on or about r r 15 for approximately 9 d 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 /> 2�/S <br /> Si 'nature Applicant-Title ate <br /> E:IPUBSV.\WIAASTER.PSIENCROACHNENTPERI.IITAPPIICATION.DOC (01108) <br />