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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - ,? r c ^ <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public WorksREF# <br /> APN <br /> � CR# <br /> C. 1 �v r r t I _ /1 EXP.DATE <br /> t v'LL r— VALID 0 <br /> (App)cant Name) 3" DRIVEWAYS: <br /> �� Ccc-� ✓L_ ,5�, f'_. STREET <br /> DS� S+—pro AREA _ �� d _ QUAD r <br /> TYPE /�tL• - ' <br /> (Mailing Address) FORMS <br /> 9NOTES <br /> (City,State,Ziip,Code) L f r <br /> X93—Cy33� _ yam' � <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <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 Sa,, ` y <br /> Of d --�'`"�—�— approximately feet/mile - <br /> y Performing the following work(description of work): <br /> Wok will commence on or about <br /> tor approximately <br /> days. <br /> i,the undersigned, certify that I am the owner of the res '`' °•I LI 4 +o p z <br /> 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 /> Signature of Applicant-Title �- <br /> �-U <br /> Date <br /> E.SPU&SV.WKVAASTERPSIENCROACHMENT PERM'APPLICATION DOC (oles) <br /> J <br />