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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ -g I� b OFFICE USE ONLY <br /> To: San Joaquin County JOB # //dUS REF # <br /> Department of Public Works APN _ CR # <br /> LC EXP. DATE I T O! <br /> [ , tiC_ VALID la D TO j O DRIVEWAYS <br /> D (Applicant Name) STREET -3W#047- plywr <br /> 1 AREA .Tor wro�U QUAD L.J <br /> 4�3�y <br /> C pJe�f J oTYPE -ZPFW <br /> (Mai l ing Address) <br /> FORMS _SS�� R-24 <br /> o tM2 `/V 11, C4 <br /> / L ('O _ NOTE <br /> (City, State, Zip Code) <br /> S 10) SM 9679 <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> The -undersigned- hereby applies for permission -to.excavate,. constr t.and/or :....otherwise encroach on County Highway Right-of-Way-on— e 0 oide..of <br /> approximately O fee /mile <br /> of 6 by -per€orming .the <br /> following work escri tion of;work) : �'vticd ull �.(� • e,��L► d'�A---..1 <br /> o w.. } <br /> Work will commence on or about for approximately <br /> days. <br /> I., the undersigned certify that I am the owner of. the respective property, or am <br /> quali ed to represent th owner, and agree to do the work.described above in <br /> acco d nce with the rule regulations of San Joaquin County and subject to ' <br /> ins a ion and approval. <br /> to <br /> S stuyyr��e of App�lJica//I�J,t a Date <br />