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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / le:5) <br /> Datef� OFFICE USE ONLY <br /> To: San Joaquin County JOB# j' REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE — <br /> �� VALID / TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ,�,� AREA QUAD "dile_ <br /> ' TYPE <br /> (Mailing Address) FORMS Z� �icJG'7eli , yi <br /> �c�� �� �' C;-�'`• � / NOTES <br /> (City, State,Z' Code) <br /> (Area Code-Telephone Number) <br /> A <br /> Sketch(Detailed plans may be submitted) <br /> A ' ) <br /> 17 <br /> 7. <br /> ,.. mow:. <br /> V <br /> YC'Y-l� <br /> PPc €C"1 " ' t -( RT�s , Stft _ L" d Cl/eIahCfa✓t� GA�I <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on Coun /HighwayRight-of-Way on <br /> the side of i� 7 approximately 6m � ee le <br /> of � by performing the following work(description of work): <br /> r <br /> r <br /> Work will commence on or about /D for approximately 2o 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 /> Signature of Applicant-Title ate <br /> Y TORMS L TEMPLAMMOCROACHMENT PERAMT APPLIGAPON.dw(0@08) <br />