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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date . / OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730 t7 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE-C d 7— JEe 0)P-C�� <br /> i VALID 0 1��3 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ��,JJ� AREA IW,4 I9&4 QUAD <br /> I1 .► 9n, Cl TYPE 'SLL-4401,E WAqj0 <br /> (Mailing Address) FORMS <br /> mo ' )esI6 , <br /> NOTES <br /> OTES <br /> (City,Sta ,Zip Code) <br /> r,:),-oCLJ 5-7(7-- 6 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to exc vate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the side of� 2-11--U—5f\ approximately 1 -7 3� Rmile � <br /> of L. '., , P r C"'- , by performing the following work(description of work) <br /> 1 l -C�' r� S �C t y <br /> 0 C_ i j S <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 /> e-er t3 <br /> Si r p scant-Title Date <br /> E:1PUB-SV.WKMAASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />