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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> I i EXP.DATE /Z i S• <br /> e,D'l�:f 1(�(p I T�(/ I -�^r lLi IG�Q t VALID //-/4-01 TO /ZiW D9 DRIVEWAYS: <br /> (Applicant Name) - { ? STREETE q. <br /> AREA UAD <br /> TYPE .✓wS IFCs�� <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �Atia.cc)eJ Map <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 t,� : YYa r1�_approximately feet/mile <br /> h d , by performing the following work(description of work): <br /> � Q <br /> Work will commence on or about for approximately days. <br /> I,the undersigned,certify that 1 am th 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 /> tee_ PSC �s J v <br /> Signature Applicant-Title Date <br /> F-VUB3V.WMMkMKPS%ENCR0A"8Tr PEW APPLIC CXUOC (011W <br /> �`uZQsSto�-►.l <br />