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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `'t <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN <br /> CR <br /> EXP.DATE <br /> (Applicant Name) VALID �� T p DRIVEWAYS: <br /> STREET <br /> tvc , AREA ?, QUAD s�v <br /> TYPE Si6�466 <br /> (Mailing Address) FORMS w - — <br /> t°�/�f �3 / a � ct gr NOTES <br /> (City, tate,Tip Code) <br /> t l - 0j '–]2- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> - k ' l ter 4 641V •L� <br /> The undersigned hereby applies for permi n to excava.e,construct and/or Otherwise encroach on County Highway Right-of-Way on <br /> the sid Of sem° : v'c�3rt s � , –, <br /> of , a•,� a proximately 0 feb�mile <br /> liV�rfy performing the following work(description of work): <br /> r <br /> Work will commence on or about <br /> y fit 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 /> wo bed above in accordance with the rules and regulations of San Joaquin County and subject to ins% pection and approval. <br /> Signature of Applicant-Title Date <br /> e:1':1-5J.t'fWlA4STMISLINCROA,HUFj,T FER!df APPUCATIQV,WC(plioN <br />