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APPLICATION FOR ENCROACHMENT MERIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 22,0422. REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE , /.A�9 <br /> Iali� �n/�GELfi VALID TO ,/•D DRIVEWAYS: <br /> (Applicant Name) STREET .moi ► <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS — <br /> NOTES <br /> (City,State,Zip Code) <br /> IZG i 446--131 _ <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 Highwaht-of-Way on <br /> the , r' tvks side of iFer�ALI,4- `4 4&rj.,& approximately �h� fee i <br /> of rI , by performing the following work(description of work): <br /> Work will commence on or about�� dAuLG }7. Pref 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 accojrdaD4 with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ignature of Applicant-Title Date <br /> Y TGPJ 4 6 TEMPIATESENCR)ACHMENT PEPMeT APPUCAMN.dcc(08% <br />