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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> � EXP-DATE �� �1 � � <br /> VALID l! 0 l DRIVEWAYS: <br /> (Applicant Name) STREET �tSan l�SS <br /> VC + AREA //Q AD l <br /> TYPE trl�� lcc�s Plr l <br /> (Mailing Address) FORMS <br /> s ,. NOTES <br /> , <br /> (City,State,Zip Code) <br /> ell D <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PL <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of Way on <br /> 'A <br /> th -� � side of, �'l*:iSW Q~4 "" approximately 4fe mile s . .►. <br /> of-- & f��� �-V AA ,� - / ,by performing the following work Wescription of work): <br /> 7Xt^•�€I� . �pjls� �irf}5�11 ' v r '+ y '�f,1� E s {rs�:i'vL� 4('+[ `v"r� i '1�f3►� � .2 '{y�,5 . <br /> Work will commence on or aboutt r%--A"A1641fV 1 - a 1. <br /> for approximately day, <br /> I,the undersigned,certify that I am the own er of the respective property,or am qu alified to represent the owner and agree to do the <br /> work des,.ctibec,�above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E�PJ3-SV.Yf4UHSTERFSIENCROACtitEHTFIER, iAPPL]rATION.00C(OiXte) <br />