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t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �}l,(�/,� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �� <br /> SYELON VALID 5 �Z 0 DRIVEWAYS: <br /> (Applicant Name) STREET nlc,U; j elf <br /> AREAQUAD <br /> �.01 SO)( /G)o TYPE _ �f fr✓"�. <br /> (Mailing Address) FORMS . <br /> _ NOTES f` <br /> (Cl ,State,Zip Code) <br /> 611 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the wiF,ST sideof_ sgs.�c�U�Nt �, ..1 approximately yE)QP 5 feet/mile <br /> ' -F2da�-1 r'»sr _�Tt� ✓r by performing the following work(description of work): <br /> 7-0 �� �i 1�l� r'°,r��'! L�� <br /> l <br /> Work will commence on or about for approximately- S r >n�}� days. <br /> 1,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 /> Sig re lican -Ti ( /] r -?�� DatA2 <br /> E:IPU&SV.WKIMgSTER.PSIENCROACf;M PER MR APPLICATION.D (01A J�dJ`�'� �� <br />