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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date L /06 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��J��i REF # <br /> /Department of Public Works APN CR # <br /> `-+• �"� �k(=��N+ ��C7Kl3i�� <br /> EXP. DATE _�7 - <br /> VALID -lh%3 TO C DRIVEWAYS: <br /> (Applicant Name) STREET !�J°,..y1`14��11�11.F <br /> AREAQUAD <br /> TYPE <br /> (Mdiling Adlress)) FORMS <br /> C"A q ll ly NOTE <br /> (City, State, Tip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans Tay be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise enc oach on County Highway Right-of-Way on the Ucr- A side of <br /> approximately <br /> - — , A' <br /> 1 � feet�Smile uvY'�r <br /> of ��z + V O r by performing the <br /> following work (description of work) : TC-jLA •'A�+c,(� <br /> Work will commence on or about 3411, for approximately <br /> U, days. <br /> 1, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent th-a 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 ap�cval , <br /> 7 <br /> � natu/ of Applicant - Title � � j� <br /> -- Date <br /> MASTER.P5;\P6%S®L (6/Co, <br />