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APPLICATION FOR ENCROACHMENT PERMIT T_ <br /> PLEASE PRINT <br /> Date OFFICE USE ONLY _ , <br /> To: San Joaquin County JOB# % 0 5 ;> REF# <br /> Department of Public Works APN CR# <br /> /' �" EXP.DATE <br /> fae'11l G &C,5 t l��i°G/!/C. VALID Z- -/ TO 6 -1 -16 DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> r 1 AREA QUAD <br /> 15-0 <br /> /5- <br /> D MI t 1 w-a l e r 1d TYPE _ <br /> (Mailing Address) FORMS > <br /> NOTES <br /> (City,State,Zip Code) <br /> �w- goo(' <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the eu� sideofA) Fj'ne Rd approximately L�00 ee mile <br /> of L�' F/ooc/ Rot , , by performing the following work(description of work): <br /> //7- // two !/2.okn tft ret r c r4l <br /> Work will commence on or about - 60 1 i <br /> for approximately 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 /> Si ture of Appl cant-Title D64 <br /> E:PUB-SY.YAMAASTERPSENCROACHMENTPER6iITAPPLICATIONDOC 1olm <br />