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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: Q <br /> Date <br /> OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 7 3;4d 7 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 2 - l <br /> C L_1 E(°)�A-)i (q t9 I-ER c C�2 I C,l_ VALID I^Z0- S TO -(- 6 DRIVEWAYS: <br /> (Applicant Mame) STREET t _ <br /> 1(0 E . �-8 r)3 TYPE <br /> (Mailing Address) FORMS <br /> NOTES _ - <br /> (Citj;State,Zip Code) <br /> `f1, y ZS � i 1 <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for�ggrmission to excavate,construct andlor otherwise encroach on County Highwa Right-oi Way n <br /> the— 90 f� side of �1 <br /> of � � approximately ) O fee mile Ly� <br /> by performing the following work( escnpf!on of work): <br /> 3 F VA (Q I 0 On <br /> Work will commence on or about /O <br /> f r ap roximately days. <br /> (,the undersigned,terrify that I am the owner of the respective propert&itm q ali e. to represent the owner and agree to do <br /> the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> J /signature of Applicant <br /> Date <br /> FA:ICENRtW.SERVICESCL621CAL1PU&SV.WKVdASTERPSIEHCROACHA7RITPERhfITgPpLiCA710N00C(09113) . <br /> 1 <br />