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APPLICATION FOR ENCROACHMENT PERMIT <br /> 'LEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# '7 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE2 -1 -1 <br /> AL i_ T' 02N i i ��(=IZ(�I C,L VALID ] I- TO DRIVEWAYS: <br /> (Applicant Name)) STREET - <br /> _ AREA UAD L C <br /> CQ 0 R E �H F� v� E� t- TYPE _ <br /> (Wialling Address) FORMS S y�✓j�L�Zcf <br /> ST-O(DC-© N � `7 5a- NOTES <br /> K-r _ - <br /> (Citf,State,Zip Code) <br /> to y(Area Code-Telephone Number) <br /> cetch(Detailed plans may be submitted) <br /> undersigned hereby applies fior p rmission to excavate,construct andlor otherwise encroach.on County Highwa Right-oi Wa on <br /> 1.�0�`I'I'1 side of ,.e_, approximately a� f e <br /> by performing the following work escription of wor{c): <br /> Arill commence on or about 1) —2- for pprately <br /> days. <br /> / l5 1 S <br /> mdersigned,certify that I am the owner of the respective grope ,or am quali►ed 7epresent the owner and agree to do the <br /> escribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> &t <br /> Signature of 0 ? 1 <br /> g Applicant�Title <br /> RVICESCLERICALIPUBSV.WKL,MSTERPSIa,CROACH47Et4TPERA1rTAPPllCATlON00C(siq <br /> 1 <br />