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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County---JOB#2 REF# <br />Department of Public Works APN CR# <br />EXP,DATE <br />VALID TO RIVEWAYS: <br />Applicant Name) STREET a J!— )— di <br />AREA QUADQ/' TYPE e <br />Mailing Address) FORMS <br />q 7 Z o <br />NOTES <br />Ciy,State,Zip Code) <br />317 s 73 <br />Area Code-Telephone Number) <br />Sketch(Detailed plans may be submitted) <br />The undersi ned hereby applies for permission to excavate,con t c %1or otherwise encroach on County Highway Right-of-Way on <br />the fiside of lgwAe pproximately feet/mile <br />ofscrl by performing the following work(description of work): <br />Work will commence on or about for approximately days. <br />I,the undersigned,certify that I am the owner of the 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 />yrq vl`Z Z 3 <br />Signature ofApplicant-Title Date <br />o <br />E..IVSSVWMOSTERPSZNCROACHMEHIPER APPLICATICN.DOC(01M) C) <br />V