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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datea"��,7�(} � OFFICE USE ONLY <br /> To: San Joaquin County JOB# �101. - REF# <br /> Department of Public Works APN CR# „� , <br /> EXP. DATE Ce)►ti. + VALID `ftt <br /> TO �-9 <br /> DRIVEWAYS: <br /> (Applicant Name) STREET ,a.2 <br /> AREA QUAD A <br /> 4145 i 1 b W -- TYPE <br /> (Mailing Address) FORMS S - <br /> NOTES <br /> e� <br /> (City, State,Zip Code) <br /> 2-v c -- '?3 / - -&a(c> <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 County Highway Right-of-Way on <br /> the /! 07-rl-,- side of etpproxh"08�-/Wt's L, II4- L 4&� ! <br /> of V�P' '2-Al- Lz,rac..c J by performing the following work(description of work): <br /> Work will commence on or about for approximately G` days. <br /> I, the undersigne , certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work desc ibove in accor rice with the r es and regulations of San Joaquin County and subject to inspection and approval, <br /> '712, <br /> Signatuicant-Title D e <br /> Y%FORMS 8 TEMPIATES'.ENO OFIMA�PEF. UOATKON.dx�008� <br />