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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / ?-, — OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> ® EXP.DATE / <br /> ►�� 7 gA7 L�2 31.3 g VALID /a4, 1SE�TO j/ r DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA �9roc.4c(oA QUAD <br /> 4t �4 TYPE S oJe, rr <br /> �s <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State, Zip Code) <br /> —A- 10 -71I�— I `7�7 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S side of 2d 3 d U b S t approximately �2O / /fee mile r- <br /> of FiAAz,-fb°` A0 by performing the following work(description of work): <br /> Work will commence on or about � --for approximately 6 4n 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 /> MICENTRALSERVICESICLERICAUPUB SV.WKWAS IER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />