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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 /> r / L EXP.DATE r' <br /> C r I� T icc Icl o ti VALID 1, oil TO � _ ORIVFNIAYS: <br /> (Applicant Name) STREET o � Ap• <br /> AREAImmoQUP.D — <br /> Z 5 0� IVa �r ( TYPE Tz- .�, VAWIIO <br /> (Wiling Address) FORMS > <br /> S� <br /> { -r1f5_2(26 NOTES <br /> � C_a_ <br /> (City, State, Zip Code) <br /> 207 - Y37- �99y <br /> (Area Code-Telephone Number) — <br /> Sketch(Detailed plans may be submitted) <br /> Plan qld SkeTA,'S- ei ckec <br /> The undersigned hereby applies for permission to excavate,construc and/or otherwise encroach on County Highway Ri ,t•ofAfilay on <br /> the_L✓e4 _-__--_ <br /> side of-_LU we•- _S 1. n,,,e l� approximately _ fe ,� �!/or _ <br /> of - n:le � _ by performing the following work(de tion of work): <br /> Work wi!l commence_on or ,oui_ 12 / ----_____-_for approximately!_ '700 days. <br /> I, the undersigned, cer`ify that I am the owner of the respective property, cr am qualified to represent the o�Nner and agree to do the <br /> work described above in accordance ,,rith the rules and regulations of San Joaquin County and subiect to inspection and approval. <br /> Signature of Ap,pkan 704le r �, . Date <br />