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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' ) " ` , OFFICE USE ONLY <br /> To: San Joaquin County JOB# tldtS'— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> i' �iny�lca '� trC7r'" VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET tE <br /> AREA 61rni QUAD <br /> TYPE <br /> (Mailing Address) FORMS z <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P7 <br /> v <br /> The undgrsigned hereby applies for permission to 9xcavate,construct apd/or otherwise encroach on County Highway Right-of-Way on <br /> the 5 J side of C- �lyt,'le ick +'� r J approximately feefJmile <br /> of ,by performing the following work(description of work): <br /> GoG C g) 51'i, u. h a 'ei gbh ili ti / ' 1 - A:a4*4M fyK14 ,44, <br /> Work will commence on or about ' for approximatelydays. <br /> I,the undersigned,certify t t 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 cordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> jr-wjeci- AUX- <br /> .+ ^ f .r' 7 <br /> SignaW of Applicant-Title Date <br /> Y TIOAMS&TEN PLATESEN=7ACHMENT PEPMT APPUCATIONNd.(MM) <br />