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.APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> C��.1�ORt�1R \'N A-CLR Zr VALIDD�/ ;-f TO-a7 x'07 DRIVEWAYS: <br /> (Applicant Name) STREETN' L00000 -- SDJ.&fth OW, <br /> SSO TR�MV S' --Ik-\CJ AREA=!�WQUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> FORMS <br /> C� lv as � 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, construct and/or <br /> otherwise encroach on County.Highway Right-of-Way••on.the side..•bf - <br /> approximately ~'' feet/mile <br /> of "�- ' ,. . by'performing the <br /> following work (description of work) : MCI ��� R1�t�C� " CS�lI►C�9 PRCLT'E.�C" - <br /> S'TALL yam, OF 10" PiJ C •ALSO R��CA'[�'Z�NO \1AINT-S tW NV�ILU DCiCt ws AV E• <br /> Faun�l�.LS�Ci�T� 3%T- V A>_v E t o o . <br /> - <br /> �.o'�►s�tu�'t�n� <br /> Work will commence on or'about for approximately <br /> U\\,\Y-UM N 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 /> inspection and approval. <br /> Signature of Applicant Title Date <br /> l96T=.PS\$HSS®L (6/0G) - <br />