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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date AA vEA,�Lf OFFICE USE ONLY <br /> To: San Joaquin County JOB# � l\ _ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID t TO Z-2 _2 al DRIVEWAYS: <br /> (Applicant Name) STREET,,, <br /> //,, AREA <br /> �rJ S4 ti d�'��� ,�v� TYPE s QUAD ` = <br /> (hailing Address) FORMS <br /> E CNOTES — <br /> (City,State,Zip Code) — --- <br /> S <br /> ,Area Cade a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> r n <br /> % coo S <br /> k 4lfk 7;P-4C-1<1 41il 60,3,9 S, <br /> The undersigned hereby applies for permission to excav fe,co struct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of .� approximately G '�R—N � <br /> of Qac ��e feet/mile <br /> by performing the following work(description of work): <br /> Worlc will commence on or about for approximately <br /> days. <br /> I,the undersigned, certify that l 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 he rules and regulations of San Joaquin County and subject to inspection and approval. <br /> nature of <br /> g Applicant it{e Date ` <br /> Fd:1CEVIRALSERIACESZCLE21CAl1P(JMV.WK"ASTER.PSIENCROACN;fE1dTPER&i[TAPPUCA71ON.DOC (09/13) <br /> 1 <br />