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, <br /> `t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: < <br /> Date I / is OFFICE-USE ONLY <br /> To: San Joaquin County JOB Jf� REF# <br /> Department of Public Works j APN CR# <br /> _ ff EXP. DATEis ', <br /> c C G VALID 1°2 t r Tb j ltYlr p DRIVEWAYS: <br /> (Applicant Name) STREET P <br /> }} p AREA r QUAD 1%!f <br /> TYPE fe k 9!5pact nen- <br /> (Mailing Address) FORMS <br /> NOTES <br /> 6 Via,' <br /> (City, State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> VA <br /> l (40 cam" <br /> The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the o�. * side of y - L—i- Q-,�- approximately .2--� feeY&I GA 54 <br /> of_ �'!oaJ@ Z.o rt , by performing the following work(description of work): <br /> t ahvt � �1 <br /> Work will commence on or about I OL 115 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 described above in ac ordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sigfiature of Applicant-Title Date <br /> M:ICEIfRALSERVICESICLERICA.LIP'J3 WMMAS TER P0IENCROACHi`MENT PERM IT APPLICATION.DOC (09113) <br />