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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: j <br /> Date -` ` ! ( � OFFICE USE ONLY <br /> To: San Joaquin County, JOS# g REF# <br /> Department of Public Works APN CR# <br /> o m EXP.DATE <br /> VALID !v TO / DRIVEWAYS: <br /> (Applicant Name) STREET L 11 E ,QD " <br /> c� I AREA a Al QUAD AoJF <br /> w�t iL�j� C� TYPE e �pGG,M e <br /> (Mailing Address) FORMSlif <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) r,-') U' 'L <br /> oro-S-% RU OrJ s twknz (� AT P"�Z—tj <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroa h on County Highway Right-of-Way on <br /> the f ASr side of N• A LPrAj P'fa,, approximately ® feet/mile 50,.r%rl <br /> of ujtdt6iL- tZT S'TOtK-ruIV by performing the following work(description of work): <br /> A SV4 I t'L <br /> OI <br /> Work will commence on o about for approximately 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 /> Si ature of App -Title Date <br /> E IPVS-SV❑IWASTER.PS EI:C90SCH%T1 fPER-TAPPOCATV1000 pjl.i) <br />