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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3Q�5Z.lo REF# <br /> Department of Public Works APN _ CR# <br /> r EXP.DATE �Ya <br /> y�n "� i t7 VALID -/6 TODRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAQUAD — <br /> TYPE a�Ea 'Pvt.E o SAL <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) e <br /> Area Code Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> CLCP OL 304KNr 4" <br /> .. <br /> � 1 ' <br /> � On�•la�-t ctcasure i^'1��, ��a99ers o,r�. 3t�- 316► fQ Mfg «y� �ou>r <br /> A�0 ?:'bn �70 C Aet,J pp We!'pa1pt. 4r /At sw*-41_ A1,0.t> -7V 40-Wwi2 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the 4 %A side of_J, i _� approximately '700 fee ile <br /> of_ L. by performing the following work( escdptfon of work): <br /> Work will commence on or aboutXallO for approximately days. <br /> 3 -Z-7 �« I <br /> I,the undersigned,certify that I am the o er of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with a rules and regulations of San Joaquin County and subject to inspection and approval. <br /> S Applicant-Title Date <br /> E.1PU9-SV.WKWASTER PSIENCROACHMEN-PERMIT APKCA:ION.DCC(CtAd; <br />