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f- C�' <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date "r; _0 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> G\ EXP.DATE �Z <br /> l- ► r [� s VALIDJy- 0 — � DRIVEWAYS: <br /> (Applicant Name) STREET • <br /> AREA UAD • <br /> p At,�r '6r TYPE • <br /> ( ailing Address) FORMS <br /> e L46.1 NOTES <br /> (City,State,Zip Code) <br /> (AreaCodeTelephone Number) <br /> Sketch(Detailed plans maybe submitted} <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-{If-Way on <br /> the side of approximately feet/mile-:---:-:- <br /> of , by performing the follow i g work(descripti f ork): <br /> c_'7 <br /> Work will commence on or about A 7 Aw P_:; --jor approximately days. <br /> I,the undersigned,certify that I am the Ze"r 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 /> -= <br /> ignure Date <br /> M:ICENTRALSERVICESICI.ERICALYI.S..SV.WK'NASTER.I'SIENCROACAiENTPERMITM'PI.ICATION.DOC(013) <br />