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APPLICATION FOR ENCROAC14MENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 OFFICE USE ONLY <br /> 10: San Joaquin County JOB REF.# <br /> Department of Public Works APN CR# <br /> n _ EXP.DATE <br /> C (_11=C)RN i A Y V ?IEP.Q)E.a-01 C E VALID - L5--i ZdKTO 'Z lDRIVEWAYS: <br /> (Applicant NaMe) STREET �,V �V c5c,�� <br /> 1 <br /> _ AREA S QUAD <br /> Y� j�� 9� E� f` S-T- TYPE beA5 - <br /> (MailingAddress) FORMS <br /> —ST-00,)C—PON 5 NOTES T- - - - – <br /> 01.� <br /> (Cilf,State,Zip Code) <br /> a0�1to 4 � f1 <br /> (Area Code e 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 side of approximately y . feet/mile <br /> b perIb ng he following work(description of work): <br /> C . <br /> c <br /> L <br /> Work will commence on or about for approximately days. <br /> 1,the undersigned,certify that I am the owner of th4e resp 've poperrttyy am qualified to represent the owner and agree to do the• <br /> work described above in accordance with the rules and regulations of S n Joaquin County and subject to inspection and approval. <br /> /3 <br /> Signature of Appli i <br /> Title Date <br /> Fd:ICEMRALSERMCESIMmcAL1Pu&sv.WKVdAmuLPSU3"cROACHMENTPERMRAPPLIcATIoK000 o9113) <br /> 1 <br />