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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> t —,VLQJ C � VALID ATE TO �y DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD ,(/S <br /> TYPE DLES <br /> (Mailing Address) FORMS svw Zai' <br /> 1 — 1 ' �C �O^ NOTES <br /> �U VIL(City, State,Zip Code) <br /> ')-o CA - 6f43-4o1"1 a <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5.eA-� 0-k-� 1PILz <br /> yr .�,� � s� �- �' 1 a� �Ic,u-� . -T�T -tom <br /> V J a-u <br /> 4�)aow 1 Com <br /> ,l n� 4- G,A-A� <br /> The ur,iorei,narL hereby applie$for permission to excavate.construct and/or otherwise encroach on County Highw Right-of-Way on <br /> the 'IW5-I- I, side of ` �t.�ir/5'�`7'"�L�, approximately�� fee DT <br /> of_�p�4Txl1G.�o , ' by performing the following work description of work): <br /> _T <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 /> Signature of Applicant-Title Date <br /> E1PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />