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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — / -g <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works36 <br /> ' "�' REF# <br /> APN CR# <br /> . EXP.DATE t — <br /> LJ b VALID 1v t4 r� ` Tp if t C! DRIVEWAYS: <br /> (Applicant Name) STREET t�J►lids®< � , <br /> lle> 410 TYPE AREAcc {i�J QUAD 6. <br /> ;cl��Hle �' - °r <br /> (iVIaA6ng Address) Tpy <br /> NOES x <br /> f_'utE� p :crl <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,construct and,/or otherwise encroach an County Highway Right-of-Way n <br /> the �E side of-- S CU 1A DQc / ( �-1 D -� p <br /> of /�6ern Ay -Approximately _��� /mile of <br /> moo.!A- rAW, by performing the following work(description of work): <br /> Work will commence on or about <br /> 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 <br /> Date <br /> MaCENTRALSERVICESICLLRICALIPUR-SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC(09/73) <br />