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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� OFFICE US <br /> Date <br /> To: San Joaquin County JOB# j DCX REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 11•t S•O S <br /> e \;01 µ e°i_ VALID eo•t5•o8 TO f DRIVEWAYS: <br /> (App cant Name) STREET ` <br /> AREA QUAD _ <br /> Ltiu, {iee TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> Cl <br /> (City,State,Zip Code) <br /> �Z oq 53 !? <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> cr <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 5 o v t, side of Rab=o d a l e— A v e n v e- approximately Ito ee ile we <br /> of_ Vov-4-t,\ \'y' by performing the following work(description of work): <br /> `tJvAv�c4Vt1 ene ;z" ,ti•e�er So; �,,,.r;A a cl2 OF too f=eef <br /> r- <br /> ��1��3 * —T��n�,� Ur co1� c-4-11' a gro�v.�w�FP� Sties-+d/e <br /> t i loc, 1 e d ✓tiQ a eY-e r0� v o,� <br /> 1 •� I�u G <br /> Work will commence on or about kwEe °� for approximately ©A 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 /> Signatur otftplicant-Title Date <br /> E.\PUB-SV.WKVNISTERPS\ENCROACHMENT PERMIT APPLCATION.DOC (01108) <br />