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APPLICATION FOR ENCROACHMENT PERMIT <br /> I <br /> PLEASE PRINT: <br /> Date iZ( rr �/ � <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# ]-�Q(212- REF# <br /> Department of Public Works APN CR# <br /> PC J l.% (o)J (, EXP.DATE <br /> VALID <br /> EET � 56( CTo �-' DRIVEWAYS: <br /> STREET(Applicant Name) . <br /> AREA QUAD _�/ <br /> �f c:.Yv ��/� ') L•r,} I TYPE <br /> (Mailing Address) FORMS 34 Z�Z�Z g �G <br /> NOTES <br /> (City,State,Zip Code) <br /> 2 off- 32-ci^ ';;S`1' -7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> A-Lb <br /> G <br /> Ps 2�z <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of SA c,--; -Al L"TD 2 r by performing the following work(description of work): <br /> Work will commence on or about V-C4avrh2'r ,.f Z o1 for approximately._Zo&d 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 /> lL (Z I (L Il <br /> Signature ofA�plicanit-Title Date <br /> AL'.CEITTRAISERVICES'.CLERICN.IPDDSVI'.R1.IASTER.PSS'I-:MROACtiLIEF(rPER1.IITAPPLiWOT J.DOC(09;13) <br />