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3,2 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2 A :ih j OFFICE USE ONLY <br />To: San Joaquin County JOB# qPLN7nV?3Ct(7--.''REF# <br />Department of Public Works APN CR# <br />EXP.DATE <br />5 VALID ( <br />177 <br />TO DRIVEWAYS: <br />Applicant Name) STREET & I <br />AREA QUAQ S` <br />TYPE <br />Mailing Address) FORMS <br />d NOTES <br />City,State,Zip Code) <br />y7- 5-29 3 <br />Area Code-Telephone Number) <br />Sketch(Detailed plans may be submitted) <br />The un rsi ned hereby applies for permission to excavate,c nstruct an otherwise encroach on County Highway Ri ht-of-Wayon <br />the . oma side of P approximately , feet/ le <br />of sr rbh — c by performing the following work(descrip ion of work): <br />Work will commence on or about for approximately days. <br />I,the undersigned,certify that I am the owner ofthe respective property,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 />nature of Applicant-Title ate <br />E+PVBSVWMM&STERPSTNL'ROACHME4TPMWAPPUCATLW.DOC(DIMS) <br />r <-v <br />e