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L—C-1C, APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin CountyJOB# 'z3o S REF# <br /> Department of Public Works IJV C' APN CR# <br /> EXP,DATE <br /> J - - M'�` }4," f'�" -VALID 6--1.5' TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD &_Ir- <br /> TYPE <br /> (Mailing Address) FORMS SS po'ly P'>�` <br /> NOTES <br /> (City, State,Zip Code) <br /> r <br /> C') <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> T <br /> `� _ _. <br /> D <br /> Li <br /> The undersigned applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the L�'T` I side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> /> <br /> Work will commence on or about <br /> for approximately F days. <br /> 1,the un ersigned,certify th t I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work des ribed abo (fin acc rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 'SIignA'tur6 of Applicant-Title Date <br /> MSCENTRALSER'ACESICLF.RCALNIJBSVIVKINASTERnEN(ROACFMEt4TPERMIT APPLICATICN.DOC (09113) <br />