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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Depa ent of Public Works <br />nn (Applicant Name) <br />(Mailing -Address) <br />(City, State, Zip Code) <br />2I2 1�5(0 5-� <br />(Area Code • Telephone Num r) <br />(Email Address) <br />JOB# <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />730052 REF# <br />CR # <br />12/15/202110 6/15/2022 DRIVEWAYS: <br />Tuxedo Ave. <br />AREA <br />TYPE <br />Stockton QUAD CC <br />Pole Replacement <br />FORMS <br />NOTES <br />SS/WW <br />Special Conditions <br />Sketch Detailed plans may be submitted) <br />N �y" <br />S <br />The undetsipned hereby applies fo�jxnnissio to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of X cv approximatelyee mile_ <br />of✓Sly; hs by performing the following work description of work): <br />Work will commence on or after IL r�_ L I for approximately days. <br />I, the undersigned, certify that I am th respective property, or am qualified to represent the owner and agree to do the <br />work described above in acco with s and regulations of San Joaquin County and subject to inspection and approval. <br />ILI 11/ <br />Date <br />