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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 0 h ., EXP,DATE <br /> VALID 0 lie DRIVEWAYS: <br /> (Applicant Name) STREET p». f, f AL , <br /> l V— AREA /Nqr 4 QUAD <br /> -` l ✓ ��•is� TYPE <br /> o cct <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code)` <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construcantl/or otherwise encroach on County Highway Right-of-Way on <br /> the ` — side of ;" ,y ` ? l ( ?approximatelyfeetlmile 5 i4-rh <br /> of '� by performing the following work(description of work): <br /> Work will commence on or about for approximately 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 descri , above in Accor ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -' <br /> i`;na u dApplicant-Title Date <br /> `d�CENtRf3Scits/CES1{:I.tRiC,itl'Pt1RSV.1;t+.rnS 7ER.�EkGRUAL:^.4}Ni PCR',iR;,Y�Lif.A R6`f.{3[A_' {59!n <br />