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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date 7- OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 13 <br /> VALID % T �_ DRIVEWAYS: <br /> (Applicant Name) STREET ".^ <br /> AREA 5?oc and QUAD KS <br /> A TYPE <br /> (Mailing(Address) FORMS �vJ <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) PjrJ 4� 1.0 C1:5_-9 3 L36 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 1VP_Ct side of VMZFI nt approximately .20/ feet/mile_Sou-M <br /> of Jeo AVAW,&L,6 f f fAZ,UE , S7Z)6jK?; L/ —by performing the following work(description of work): <br /> Work will commence on or about_LU.-Q.<f (J/t3 for approximately SAIF 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 of Applicant file Date <br /> vita .Y.7 usn",tP5fEg7iQlu-FrPm,NrlP?mnofwcc om <br />