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9-5 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '� _ J <br /> �Tr '7 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> L/2• LAS, EXP.DATE ,a <br /> f L VALID f-AIN 44 TODRIVEWAYS: <br /> (Applicant Name) STREET - 1 At. <br /> 7 � AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> j NOTES <br /> .�7c�f)i7, tI t i <br /> (City, State,Zip Code <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> aL) '06 Q <br /> �f <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the _side of approximately feet/mile <br /> of ,by performing the following work(description of work): <br /> Z: 3 rnrL Is OF A4 <br /> F! <br /> LW <br /> r <br /> fn�r£/ZlV ,. ler- <br /> Work will commence on or abou . !A for approximately da <br /> . s.Y <br /> 1, 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 inpaC-4rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ?Iq AD <br /> ure of Appli nt-Title a e <br /> YiPOnMS L TEMPI)TESIENCMA.CF'MEN T PERMIT APPUCATION.dw_(O&CB) <br />