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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date jB�-P% OFFICE USE ONLY <br /> To: San Joaquin County JOB# //OGbar REF# <br /> Department of Public Works APN CR# <br /> VALIDATE /Z'iS <br /> e0 S ��1 eome VALID /�/G'O�f TO /Z /�•6�j DRIVEWAYS: <br /> (Applicant Name) -rQranl5hl STREETcz:zo <br /> - <br /> t, AREA m2 I�GiIZ� s t lvf TYPE $ <br /> (Mailing Address) FORMS <br /> NOTES <br /> btiltT�P�sk Cf� <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ctnd <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of '' °v t v �n vy approximately feet/mile <br /> Of by performing the following work as Iption of work): <br /> Work will commence on or about for approximately days. <br /> I,the undersigned,certify that ,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 /> C_�N-% <br /> Date <br /> Signature W Applicant-Title <br /> G^HASJVMYM519tP5FNCRGOA1011P9WifPPI.IGTONDOC lm�l <br /> '�Ld2QrSE-i-Nt <br />