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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB# 7-god 5z-Zo REF# <br /> Department of Public Works APN CR# <br /> r i { EXP. DATE S - I .t74"t <br /> VALID p TO DRIVEWAYS: <br /> (Applicant Name) STREET ,? ` <br /> ; r AREA C5 Aon QUAD 5A « <br /> C TYPE o <br /> (Mailing ress) FORMS <br /> NOTES <br /> (City, State,2ip Code) <br /> ( <br /> 4a Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Pm* 306'(ve3116- <br /> P-2341 <br /> (62234d Me?, Ave. <br /> 2$746 e 2rw-754 Ave . <br /> 2883q ��^a�,y� Vve <br /> e9m Ile Apl�f, <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of "� i , by performing the following work(description of work): <br /> �. l <br /> o� ILx CC,,y 5, re h )V, 4-2-, 7l F r '�(i tr 1 ct to <br /> Work will commence on or about (-3 IS 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 /> Signa urevfApplicant-Title ' Date <br /> E'PUB-SV,WNIMASTER.PSU NCROACHMENT PERMIT APPLICATION DOC (01,00) <br />