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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date —1 S / OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR <br /> n # <br /> (1 ,) EXP.DATE <br /> (Applicant Name) STREET VALIDC /�'�'..� DRIVEWAYS: <br /> 1 - ' `c * <br /> �6 4 U LA a I L Ni AREA ; SQUAD .Sf:� <br /> TYPE <br /> (Mailing Address) NFORMS <br /> OTES <br /> ES 5` C � � � "`5� (✓ <br /> t� <br /> z�y <br /> (City,State, Zip Code) <br /> 4/0�-- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans maybe submitted) <br /> The undersignside ed hereby applies of plies for permission t <br /> theo excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> of 'Cc.�.,� �tw e 1 approximately=_/,kU <br /> QtWmile <br /> b e�L + ,by performing the following work(description of work): <br /> XSr eI le i` ve <br /> Work will commence on or about_ 7—1--t S for approximately p <br /> 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 ve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ignature of pplicant-Title Date <br /> M:ICENIRNLSERWCESICLERICALiPNBSv.WKUMSTER PSB4CROACHMENTPERMIIAPPUCATION.OoC(0913) <br />