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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> t <br /> Date j' �' f '� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 'T,3C�']�—' REF# <br /> Department of Public Works APN CR# <br /> J ,, EXP.DATE 20,s / <br /> �)I 0 C�r M VALID T6 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA F;zav" CMQ QUAD f <br /> TYPE �GR.� QiT Z ' <br /> (Maii Address) FORMS <br /> l 1 1 � D NOTES U <br /> (City,State,Zip Code) <br /> `a_u 'L-I - C-i =-L[ 0[- S <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 Highha�ay Right-of-Wayon <br /> the Pof-IIJ r;L side of , -�I� �� approximately q f5� (fe t/mile <br /> of ' t c V�f �C _ rP��r ��„� by performing the following work(description of work): <br /> Work will commence on or about DJ 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 o pplicant-Title Date/ <br /> E,PUBSV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />