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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 / <br /> C� C VALID p TO /Z / DRIVEWAYS: <br /> (Applicant Name) STREET ,? <br /> AREA QUAD <br /> TYPE a�C 11cG e <br /> (Mailing Address) FORMS �./a l �! <br /> NOTES <br /> c� <br /> ICA , 6131 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ,qCE A- WA"ivi(I <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 V-S3 approximately Xg7S dee mile <br /> of '1� by performing the following work scription of work): <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 /> e e�c elm"kA-V'- (,- ( I,( <br /> Signature of Applicant-Title Date <br /> E:PUB-SVAKWASTER.PSIENCROACHMEW PERMIT APPLICATION.DDC(01/DB) . <br />