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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: , <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# F RE <br /> �3�d7`7 <br /> Department of Public Works APN _ RE .# <br /> EXP.DATE 7 14 <br /> CA L I T=Q P, i A Y V J9 I EP-,�)ELU 1 IE VALIDj i _ TO _ /¢ DRIVEWAYS: <br /> (Applicant Narhe) STREET `Se,sroL SAVE. <br /> AREA :S-j '&-r6 A) QUAD Cc- <br /> (o 0 E F)9� E S-TTYPE 'PD6" taaLE <br /> (IUlailingAddress) FORMS ,� ,e L� ,•�� , ,,� �� <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andfor otherwise encroach on County Highway Right-of-Way on <br /> the K,) , 'h side of f' � ,;�-, approximately 1 fi ile <br /> of j'-'LL, t y by performing the following work(description of work): <br /> Work will commence on or about n _ f r approximately (� 17)y) days. <br /> 1,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 /> Signature of Applicant-Title Date <br /> M.'ICEMRAL6ERVIOMCLER'CAL1W8SV.WRNIASTEPPSIEHCROACHR1Et4TPERh1RAPPL1CATIOItDOC(09113) <br /> 1 <br />