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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> L <br /> Date _ OFFICE USE ONLY <br /> To: San Joaquin County JOB #Ag??;�7 REF # <br /> Department of Public^ Works APN �- CR # <br /> vv)Vnixte VALID TO� ..! DRIVEWAYS <br /> (Applicant Name) STREET .'tr �T <br /> AREA A,,Vz'4) QUAD 1W <br /> 4cj `7 TYPE ?Lk-A, <br /> (Mailing Address) FORMS :�t�� <br /> L N0�-� L�- ; NOTE <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 <br /> otherwise encroach on County Highway Right-of-Way ori-the NOR-0.+ side of <br /> approximately feet/mile <br /> of by -performing the <br /> following work (description of work) : CL.-OSVtZE OC- Ff j �- 'j_ � ^�vk � <br /> Work wx'11 commence on or about V C Via : C 5 for approximately <br /> ONc <br /> days. . <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant - Tit11 _ Date <br /> DU�S22R.PS�PB35'' L �6/00I y -I'..�. ,k--_.C,�.•••^-----' <br />