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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �_45'" ON OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,f®mjJC"' REF# <br /> Department of Public Works APN CR# <br /> J <br /> 36_�ican <br /> EXP.DATE — <br /> _CV In <br /> '.- YI VALID TO 3'6 DRIVEWAYS: <br /> t Name} STREETtc2w�'Fo� , <br /> �t71 J Lo� Y.. ,��n � AREA T'KrV QUAD KitA) <br /> _ ! lYc�ld� TYPE TZA-PPec CoA7TQo(. C _ <br /> (Mailing Address) FORMS , <br /> NOTES <br /> (City,8bte,Zip Code) - — ----- <br /> (Area Code-Telephone Number) — ---- - - - - <br /> Sketch(Detailed plans may be submitted) -- - <br /> e--lQrt s <br /> The undersignedray applies for ermission to exca ate,c nstruct and/or otherwise encroach on County Highway Right-of a on <br /> the t /side of approximately feet/mile /gyp <br /> Of -� <br /> r by pe orming thefollowing (description of w rk <br /> rA <br /> ar nC(1t ru <br /> Work will commence on or about__� � for approximately __3da s. <br /> Y <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 d ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> "neer 514/ <br /> ignature of A plicant •T"rfle Date <br /> HPUB.W.W S,ERP5ET(MOVAWNf P£RWAMICAlpNIM(p%aa) <br />