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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ,( <br /> Date , / l OFFICE USE ONLY <br /> To: San Joaquin County <br /> JOB# 3GYJSZ-/ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE /S <br /> Rq � VALID / J/ 0 / DRIVEWAYS: <br /> (Applicant Name) STREET T> <br /> AREA ockE QUAD ,tlE <br /> TYPE l6 — <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> W40-4 kf� <br /> 3 to 2-9�1 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway R' ht-of-Way on <br /> the side of J�'( . �Q L approximately !b.�v feet/ it <br /> ofJ by performing the following work(description of work): <br /> 99' E3� C 1S l�� y JA J a J <br /> Work will commence on or 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 /> t��lmkv>� 4/-1J (1 <br /> Signature of A�pplicant��Ttle ate <br /> E.WUB-SV.WICWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC(01108) <br />