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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date I -- if) i O 16 <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />of -q&- 111 ftp` it`d <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />%/QGG REF # <br />CR # <br />glIlles <br />�/® /g3 TO 2 Pi fS DRIVEWAYS: <br />AREA/bFi <br />TYPE <br />e <br />QUAD (6 <br />p6ye <br />FORMS <br />NOTES <br />�as6 <br />/071 t // 7,1 <br />2.1 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the i?c, Y Irk side of r SIt ALA -,i—tax 2A c Y�14 2-0 approximately V'fie mile <br />of by performing the following work description of work): <br />tii (VkE c,i ri yz Baru is " (1oAID RAtSc--2— <br />commence on or <br />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 />Signature of ApplicanV Title Date <br />Y PORMS d TEMPlAiEICENCROACHMENT PERMIT APPLICATION daa(OPIQP) <br />