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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date p �l65 OFFICE USE ONLY <br /> To: San Joaquin County JOB# _7 REF# <br /> Department of Public Works APN _ CR# <br /> PCEXP.DATE In -19-115 <br /> C� VALID _ - 1 TO (r -C S-I DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> Ci �7 ilfG�� eai' {��e TYPE _Qin <br /> (Mailing Address) FORMS _G� IAZVV p?61 <br /> ll� <br /> ?S-60,5— <br /> ( 60 f NOTES/ J J <br /> (City,State,Zip Code) <br /> 76 0°/ S T <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitte_d,)? <br /> �ltl \ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the We- --s7- side of -DR A I.5 r;oAD approximately s mile orfl <br /> of- ///,t/-y _,by performing the following work(description of work): <br /> Work will commence on or about J for approximately days. <br /> 1,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 rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant•Title ate <br /> uxartRxsEmasaexcuaesv.»aw,sstae�rRa,Gne:R�xvrfaacunaiooc�;�,a� <br />