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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 -g `a 2 e l! OFFICE USE ONLY <br /> To: San Joaquin County JOB# 300 t;Z- REF# <br /> Department of Public Works APN Tl!;-_ CR# <br /> EXP.DATE PlltTl!�iM 3 r16 1-1 4A 7 VALIDs 5 � 0f ® � DRIVEWAYS: <br /> (Applicant Name) STREET MY"11 <br /> AREA -faek� j QUAD <br /> � �� TYPEel( c,� <br /> (Mailing Address) FORMS 5S ao✓ �9 i, <br /> NOTES <br /> (City,State, Zip Code) <br /> �1®� ® 31i�-- 1 `7i�'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 Highwa Right-of-Way on <br /> the 1� side of L �1 approximately 1.20 _ mile S <br /> of ' — �o�f�11by performing the following work(description of work): <br /> Work will commence on or about �.� �� ��P� for approximately d—">,'n 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 /> M.ICENTRALSERVICEMCt ERICAUPU6-SU WKWASTER.PSIENCROACHMENT PERMIT APPLICATIONUOC (09/13) <br />