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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date N m r 21 2L\6 _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1/0005- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / /S <br /> VALID // o /S TO DRIVEWAYS: <br /> (Applicant Name) STREET llc?LT <br /> ' <br /> AREA 5"e,&roAl QUAD <br /> TYPEAD <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) 3,41,P 445VZ6W PAAe4,0E ®Al <br /> K 3�3 _ o Anit. -r0 9.'.3 D ePM X <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 side of _approximately feet/mile <br /> of eLAA T by performing the following work(description of work): <br /> Work will commence on er-abeat- Z\ 2p\5 for approximately 2 days. <br /> I,the undersigned,certify that I am the owner of the respE!ctive property,or am qualified to represent the owner and agree to do the <br /> work described ab e in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> C �W <br /> vi)i <br /> ature of Applicant- itle Date <br /> E1PUB SV:WKUMSTERPS`ENCROACHMENTPERMIT APPLICATION.DOC)01M) <br />