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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: P <br /> V <br /> Date C1 14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( ( a a o 5 REF.# <br /> Department of Public Works APN CR# <br /> I<N 1 FC ZI Ve- Com'IS�PVC-1 p-4EXP.DATE <br /> VALID 9Zq q —/ 0 <br /> e <br /> DRIVEWAYS: <br /> (Applicant Name) STREET <br /> vt <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS T tea/ Vt es <br /> C4 NOTES — <br /> ► (City,State,Zip Code) 2ocac( CI6 ►�t<,' - - - - <br /> C �O� n un� i soh <br /> au/ <br /> � pan <br /> (Area Code_e Telephone Nurnber) <br /> Sketch(Detailed plans may be submitted) <br /> se-: � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way <br /> the side of y on <br /> of approximately feet/mile <br /> by performing the following work(description of work): <br /> 1 c"1 r 1 S/C�a15 <br /> u <br /> Work will commence on or about for approximately /L1171/11 <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 /> 717, .Srcr X41 46e5 <br /> ASignature of Applicant e Title - <br /> Date <br /> PA:ICEMRALSERVICESICLH21CAL1PUBSV.WRVAASTERPSENCROACHA1ENTPERAIITAPPLICA-nOnoc(qlq <br />