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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 0 0 REF# <br /> Department of Public Works APN CR# <br /> �,p } . EXP.DATE -1 -1 <br /> f�c`7 Uf VALID —�'-- TO ( -14 DRIVEWAYS: <br /> (Applicant Name) STREET �K,,n 5 Q * <br /> AREA LpCke&rat QUAD <br /> TYPE <br /> (Mailing Address) FORMS /WW P, <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted), <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the side of y,5 VIA> approximately fee ile` 0 <br /> of C-,a-Arm i by performing the following work(desc iption of work): <br /> �1�ti> l ier 1't"A.�� '�rt► <br /> LX <br /> Work will commence on or about for approximately q riays. <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 /> Signature ofAppiicant-Title Date <br /> fl.% P'0 �/o km- <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.VV.STER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) Please return permit 1 <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton, CA 95201 <br />