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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dateyi I (-) I I -�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE .5--15-Z c>j <br /> r',' <br /> VALID ;�=�- �] TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA L QUAD <br /> TYPE <br /> (Mailing Address) FORMS (A."') <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The u dersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the vk- side of VkvA-, approximately TCU` feetkM te- C��.S <br /> of C...("y X-y xye ,by performing the following work(description of work): <br /> u h �4�n.-� C� ,rte . C)© �- C� 0-1? �c• <br /> Work will commence on or about ("3 for approximately ( inPe <br /> t. 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 /> Si ature of Applicant- Date <br /> Y_\FORMS&TEMPLATESIENCROACHMENT PERMff APPUCAnON.doC COB108) <br />