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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ �nD �j t �S� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> � <br /> // EXP.DATE -,�`'F <br /> jy C4 , _ VALID TO 5 - /5 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA UAD <br /> TYPE <br /> jj / (Mailing Address) FORMS <br /> ije �a 6 r4 r,,,p�, a S'�C?�- NOTES <br /> (City,State,Zip ode) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) — <br /> �ee <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ro siaof 1J - -MC-?)A Rc'Q approximately feet/mile <br /> of_�,_� j N �d1 S A ck 4y^1 ,by performing the following work(description of work): <br /> CLc- ac rd s` &CAa/aD kid a c1 rc /c� c c� <br /> C—Sh y- C � �Vl <br /> Work will commence on or about 7 for approximately /ep 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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title — Date <br /> -r, <br /> !.I:iCEHTRALSER4'ICEd'ClERiCA1WU8SV.YrRV.4iS7FR.PStENCROAGHF.1ENi PER!!RA N3CAi!ON.DOC(09/73] <br />