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PLEASE PRINT: <br />Date <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />�0/, I, <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />�fok 3/rte, <br />(}Arse C)ode <br />-Telephone Number) <br />J r. r1/i�C✓tt .�Lyti, <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) `. y�c <br />I�rtJ <br />9 le, <br />R� <br />The undersigned hereby applies fqr permission to excav e, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the_ <br />side of ( u we a v i1 approximately I / L \ rfeeBmile _� <br />of C i 5 h.r e C. e r, _/ / , �_/'— , by performing the following work (description of work): <br />s ✓c�lti� P <br />Work will commence on or after - 2 for approximately ! days. <br />I, the undersigned, certify that I am the of the respective property, or am qualified to represent the owner and agree to do the <br />work described above in accordjant* withthe rules and regulations of San Joaquin County and subject to inspection and approval. <br />Date <br />