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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � OFFICE USE ONLY <br /> To: San Joaquin County JOB# /l 000 REF# <br /> Department of Public Works APN CR# <br /> �L�/'.• � '�ly"� EXP.DATE 3 s► is <br /> VALID 3 3► ►S TO -31 DRIVEWAYS: <br /> (Applicant Name) STREET ke. e- R2 e4sq /ty ' <br /> AREA -Z qe y QUAD -5W <br /> TYPE SMP. 9-04D C605"&E <br /> (Mailing Address) FORMS -- <br /> � <br /> Z NOTES q,J 72 -)-t-DAY 9.,a-;-, Z.95z,4—= Asn/ 3 3► l5" <br /> (City,State,Zip Code) F4 o :oo A v 726 3:,P,--, P. ter, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 61 3J; <br /> ✓ r3i—/ <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 ,by performing the following work(description of work): <br /> Work will commence on or about for approximately 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 les and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E-TUBSV.M MSTERPS1ENCROACHMeNTPERMITAPPUCATION.DOC(01108) <br />