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A.l?pLICATIONFOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �p (�g REF# <br /> Department ofRublic Works APN : CR# <br /> EXP:DATE Z <br /> C L— VALID /$7 T L DRIVEWAYS: <br /> {Applicant Name) STREET <br /> owl <br /> �o s. <br /> AREA <br /> .� i/) TYPE <br /> {Mailing Address) FORMS ' <br /> NOTES <br /> {City,State,Zip'-ode).`: <br /> (Area Code-Telephone Number); <br /> Sketch(Defailed_plans may be submitted) <br /> " ,t � <br /> The undersigned hereby applies for permission to excavate;construct and/or otherwise encroach on County Highway.Right-of-Way on <br /> thelapproximately c feetlmile. <br /> of �� T <br /> by performing th following work;(description of work); <br /> Work will commence on or about � �.;j/. y <br /> - �- - for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified o represent the owner and agree to do the <br /> work'described above in accordance with tbE.rulesand regulations'of San Joaquin Countyand ubjectto inspection and approval. <br /> natureApplicant-Title Date <br /> EwesvwK%WTEP-aSAENa�Qn MeirrE%nrnaPocnnaaooc jo„oe� <br />