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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ¢ OFFICE USE ONLY <br /> To: San Joaquin County JOB# �(,ti3(��3�Y -,� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE l U-f-zdf U <br /> VALID �Z2--�-c�-(-2c✓ f� DRIVEWAYS: <br /> (Applicant Name) STREET " <br /> AREA QUAD ,nj IFL <br /> 1y'pr P, rk- P I CSL' TYPE b* Q .� .. <br /> (Mailing Address) FORMS S�SIW U2, 2 <br /> C) <br /> NOTES <br /> '3'7'2-� <br /> (City,State,Zip Code) <br /> �C175 ,I 9 D <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 Right-of-Way on <br /> the W 2,5T side of t 0324'-- ` ictp y Avg- approximately 137? f ed feet/mile <br /> of C--N- 12,C) by performing the following work (description of work): <br /> R e of c,�a- d el ex-i-r-o.Feel r)a.e� <br /> Work will commence on or about -0 -I (5 i for approximately days. <br /> I,the undersign d,certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work describe ab in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br /> t 4- <br /> natu of Applicant-Title Date <br /> M:\CENTRALSERVICES\CLERICAL\PUB-SV.WMMASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />