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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 'ATO _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA <br /> L/UC/6 LL)eSt LTYPE E vw< X42 <br /> (Mailing Address) FORMS <br /> NOTES l <br /> (City,State,Zip Code) <br /> 31 (, - 17(,J <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ,,� z <br /> VA <br /> 1�Iv1 > I l j Ss <br /> The updersigned hereby applies-for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the - side of Cuz' approximately �-1-7 ee mile ,5�=+ <br /> of o S ,by performing the following work(description of work): <br /> 94 <br /> Work will commence on or about `7— 1 -1 `S for approximately Co (> 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 descri above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -� Sig r plicant-Title Date <br /> M ICENTRALSERVICFSICLERICALAPUB-SV.WHIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />