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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2,'C>" <br /> Lii `�j? ]=�(�tzs r")r-8- T)red f'+[- VALID -l�11 TO S= 1 y-2-p\� DRIVEWAYS: <br /> (Applicant Name) STREET VUNCAJa RD. ' <br /> AREA QUAD <br /> TYPE gna8tCZ1u F <br /> (MaiI4 Address) FORMS <br /> NOTES <br /> (Ciq,State,Zip Code) <br /> g2'-7 - 311 o <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The un a ign hereby applies for permission to excavate,construct and/or otherwise encroach on Cou ty ighway Right-of-Way on <br /> the side of ;c, ,k/QUn ?, approximately feet/mile <br /> of b performing the following work(description of work): <br /> C i P) 7 s t <br /> Work will commence on or about for approximately Orr' _ 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 /> C�6 <br /> 5 <br /> Signature o Applicant-Title Date <br /> EIPUBSV.WKIMASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (01M) <br />