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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1 <br /> Date 7 \ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73ee-5z-18 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Im <br /> l <br /> C E1��S�(� VALID A l l-z TO S 1 1L DRIVEWAYS: <br /> (Applicant Name) STREET V,%vE2 'moo <br /> _ AREA QUAD 5a ' <br /> TYPE 'T�€�acrl� a>✓ 13t=u��bLE <br /> (Mailing Address) FORMS WWF le-Z.7 <br /> NOTES <br /> C.�)S g <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may besub fitted) <br /> Vv\k - klS ►� l l <br /> The undersigned hereby applies for permission to exc vate constr ct and/or otherwise encroach on County Highway Right-of-Way.on <br /> the side�f 1 11- r� y� e �Q o�e>n i` pproximately a,1 66` I-1 feet/mile <br /> of " C Cao ` `I `' Seer 5 , by performing the following work(description o work)ii <br /> , . <br /> Work will commence on or about a 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 Applican - le Datell <br /> E:1PUB-SV.YMVAASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />