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APPLICATION .FOR ENCROACHMENT PERMIT <br /> pLWE 'PRINT: <br /> Date �3 OFFICE: VSE ONLY <br /> To: San Joaquin County JOB # lIA2!L REF # <br /> Department of. Public: Works APN CR # <br /> EXP. DAT <br /> ( sem VALID r/'�04 TO DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> AREA :5 CN QUAD _ <br /> ( c TYPE A/04Yt� <br /> � oAA)r AF <br /> (Mailing Adhas) FORMS. <br /> NOTE - <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number). <br /> Sketch, (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, co st ct and/or <br /> otherwise-encroach-on County•Highway Right-of-Way•oR-the <br /> �i approximately feet/a"e Egg-1 <br /> ofhy."per€orming the <br /> following work (descri tion of:wor ) : <br /> Work wi .1. Commence on or'about for approximately <br /> CO P, days. <br /> I, the undersigned certify that I am the :owner' of,the respective property, or am <br /> qualified to represent-the owner and .agree, to. do .the work described above in <br /> accordance with the rules, regulations 'of.San Joaquin County and subject to <br /> inspec i and ap roval . <br /> ignkture pplicant 'Title Da e <br /> !®STBR..FS\ ,CSIlL <br />