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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRI IT: <br />Date <br />To: San Joaquin County <br />��Public Works <br />(Applicant Name) <br />(Mallin dreg) <br />(City, Stets, Zip Code) <br />Z 'f Z L 5� <br />(Urea Code - Telephone Numr) <br />?C,4---�r rw.:% tg • Laws. <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 />f <br />may be submitted) 2 <br />x <br />E� <br />q C� <br />lu <br />The undersigned hereby applies forpertnisslon t�axgavate, conshid ardor otherwise encroach on County Highway Right -of- ay on <br />the side of u b _apprommatsly tLA ie%Ymile <br />of I by performing the following work (description of work): <br />Work will commence on or atter for approAmately days. <br />I, the undersigned, certify that I am ttr respective property, or am qualified to represent the owner and agree to do the <br />work described above in ac000arI63 with and regulations of San Joaquin County and subject to inspection and approval. <br />