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APPUCATMM FOR ENCROACHMENT PERMH <br /> PLEAa <br /> Date _ -� p ___- <br /> oFFlcl=USE ONLY <br /> To: San Joaquin County JOB <br /> Department of Public Works _ -_ REF <br /> APN CR m <br /> - ' EXP.DATE Xifd <br /> d _ _ — <br /> 1 l VALID <br /> - <br /> (Applicantrga�e) STREET ' 0 "err DRIVEWAYS: <br /> �0? "'09 <br /> 10 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> ate, Zil®Code) -- <br /> (Area Code- Telephone P'vrAbar) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-ofWay on <br /> the side of .�/3$ d12 wt o l a� S <br /> of_ �v A_ K j� approximately ee mile <br /> 7-,�k ,by performing the following work escription of work): <br /> Work will commence on or about O <br /> for approximateldays. <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 Appftant e Title �7� <br /> Date <br /> 1110EN1P41EER!!CESGLERICAI.IPUOSV.Il'i(l`/:ASTER-F51?1CR0liCH:`ENT FERhffi AFPLICATION.000(0.113) <br />