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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: r <br /> Date "j t° �' OFFICE USE ONLY <br /> To: San Joaquin County JOB# f ✓'� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE "S Z8 04 <br /> L4 C } , Ftl /Z � - VALID 3 2S TO 3 0 DRIVEWAYS: <br /> (Applicant Name) STREET q4:% <br /> AREA 's'4,L-TA QUAD 5W <br /> C0 R,-Il TYPE —T96 &JG 449D�'�- ,osll <br /> (Mailing Address) FORMS <br /> NOTES <br /> S1 -7-0't/ ', ys e <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> c � ' <br /> M1 �76r R� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the /3r7 h side of b a' 6 R- approximately -1"Z feet/V <br /> of ba til 14e-4= A- ' ,by performing the following work(description of work): <br /> Work will commence on or about - 3 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 /> dll� 3 ._ 16 - 07 <br /> Sig at re of Applicant-Title Date <br /> v%FOPMS B TEMPLATE PEPMT APPLFCATION.dac 10a%) <br />