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PLEASE PRINT: <br />Date <br />APPLICATION FOR ENCROACHMENT PERMIT 1 <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name <br />(Mailin Address) <br />C"i,co c A , Qo . lz4s-)z <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />JOB# <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />7������ REF# <br />CR # <br />TO DRIVEWAYS: <br />{- f� , Rd <br />AREA <br />TYPE <br />- , r QUAD <br />h <br />FORMS <br />NOTES <br />5S/1�t/t�/->_�i <br />The undersigned hereby appl'pk for permission to excavate, c nstruct and/or otherwise encroach on County Highway Right -of -Way on <br />the Mde•ef \-A VC1nEha-> nn approximately feet/mile <br />of _ _ _ _ ^ by performing the, following work (description of work): <br />Work will commence on or about M �C-z '7LIMIA for approximately — 10 <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 />Signa ure f Applicant - Title Date <br />Rec t,4 vegk <br />M:(CENTRALSERVICEMCLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (09/13) <br />