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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,�/.�?pS REF# <br /> Department of Public Works APN CR# <br /> t t� t EXP. DATE <br /> CA?. Ott <br /> 9 lS d <br /> �u i1 h <br /> e C �C 1 u �4 Ns�` VALID - /.OBJ TO a97 <br /> DRIVEWAYS: <br /> (Applicant Name) STREET ;V7 <br /> AREA QUAD <br /> J TYPE _ <br /> o iJ <br /> (Mailing Address) FORMS S w, r 2.9 <br /> Si6c K+3 rk NOTES <br /> (City, State,Zip Code) <br /> Zc�4 - 9t(3—(A I <> <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> -P 33Ss � s � srt <br /> Lf <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the F_y sA side of approximately t4 a-:I' ee mile s� <br /> Of_ ralIr, '4,3t by performing the following work(description of work): <br /> 1- yVA C "t ht2 ( <br /> v <br /> Work will commence on or about for approximately Z 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 Date <br /> YVORMS 3 TEMPLATES'ENGROA.CHMENT PERMIT APPLICATON.dcc IMM) <br />