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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �,� REF# <br /> Department of Public Works APN p/rl'— U. � CR# <br /> J r-, . r EXP.DATE —45`2-O <br /> �6ila <br /> o �I. �''�C c xc Li�,�f VALID -Zai TO DRIVEWAYS: <br /> (Applicant Name) STREET J <br /> AREA v QUAD <br /> 2 3 A P& TYPE <br /> (Mailing Address) FORMS 5 SAOGO - , =2- <br /> r L „ Z NOTES <br /> d �� _)5 W2 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The unde�igned hereby applieq for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the s side of �c�� l %c' approximately 9 feet/mile 5-dg,.!y <br /> of 5k. -, by performing the following work(description of work): <br /> Work will commence on or about a," 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 /> 4 - -Z-0 t 3 <br /> 19 , <br /> Signaturi ofpplicant-Title Date <br /> YAFORMS&TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc(08/08) <br />