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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />—111 of.., <br />To: San Joaquin County <br />Department of Public Works <br />( pplicant Name) <br />d 22 ISI le�w <br />(Mailing Address) <br />I� �I <br />City, State, Zip Code) <br />(Ara Code - Telephone Number) <br />PA "o � <br />(Email Address) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />Sketch (Detailed plans may be submitted) <br />C� Y -.QV <br />-� ©cz-G '- <br />r -a,1 X� <br />220it5'l <br />Then rsigned hereby appli for per ission to excavate, construct and/or otherwise e roach on Count highway right-of-way on <br />the �� G, si e of r' i'1 0►1 approximately _ feet/ 0 mile <br />of , by performing the following work (description of work): <br />Work will commence on or after <br />for approximately <br />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 />n <br />gnature of Ap 7 <br />t - Title Date <br />