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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ) I-3 , ' )oI OFFICE USE ONLY <br /> To: San Joaquin County JOB# (>OC2 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> �lJG1NF}� C( STRGt� I U��1 VALID Z�2-2[31ZT0 2 2c,/Z DRIVEWAYS: <br /> (Applicant Name) STREET <br /> -s T�f C- '`qt's AREA /�G�(1„v. QUAD _ <br /> TYPE p�� <br /> (Mailing Address) FORMS �S- t►J `� <br /> A A TteA ( 9, 35r/, NOTES^(�k cs caw. <br /> ((Cutty, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitte ) <br /> The pIdersigned hereby applies for per issi to excavate,construct and/or otherwise encroach on Canty Highway Right-of-Way on <br /> the side of I approximately feet/mile ter <br /> of 1.4 W Y. 1 r by performing the following work(description of work): <br /> Work will commence on or about av lQi- for approximately / — Q- 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 /> ignature of Applicant-Title Date <br /> E:IPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (OLOO) <br />