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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��" /;z 2e1Pr1 OFFICE USE ONLY — —� <br /> T i <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# ----- <br /> EXP.DATE C -- — � <br /> V .yl/ Com.,� f, /,�i�G _ VALID 9-ff-ay TOQ•/SDg� DRIVEWAYS: <br /> (Applicant Name) STREET ,q/ 9 _ <br /> 5 GCL6-_ �C.�i: _ TYPE AREA —T�biPiVe�t/ QUAD �j --_—I <br /> (Mailing Address) *---� <br /> FORMS <br /> NOTES _ <br /> (city,a�ate,Zip Code) _ _—__-- <br /> qss <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 Coun Highway Right-of-Way on <br /> the_ Ef157--_side of_ IIAIAt 4h approximately____ /p 1191ffTeetimile <br /> Of &AFA 1by performing the following work(description of work): <br /> Work will commence on or about !/ q for approximately, % _ days. <br /> f,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 /> pAa�z] <br /> Signatugreof Applicant Title pat <br /> ex:asvwxwe,srEF=s�Hc,�etx�vx��*�-�;:;,n:�ra.pu� ;;roel <br />