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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE p ! <br /> VALID Td /-0/VbtDRIVEWAYS: <br /> (Applicant Name) STREET 671,911,4^4411 <br /> AREA Lii✓lEat� QUAD , /05 <br /> �:11 �)1,ki V1 VA CL . TYPE /YI P19�� Lb G` 1iQE <br /> (Mailing Address) FORMS s <br /> -� NOTES ! Za!Z1,q ,'60 p/YJ, TO <br /> City,State,Zip Code) <br /> I '8 t-�-A DI<1:-1), <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 side of approximately feet/mile <br /> Of ,by performing following work(description of work): <br /> D�9 <br /> aM <br /> DAA4o�/.6.6:1 /W/ 41 PIZ/)e7 <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 /> Sig tune of Applicant-Title Date <br /> F-VUMV.WKWSTERPSIEWROMJMENTPEiSUAPPUCAT =(MMI <br />