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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE Pillfi l/ <br /> Date /� QQ 9 OFFICE USE ONLY <br /> To: San Joaquin County JOB# '(- REF# <br /> Department of Public Works APN _ CRA,, <br /> EXP.DATE —.._.. , •1-6 <br /> 'k .�' VALID •O TO t� DRIVEWAYS: <br /> (Appllaant Name) STREET , <br /> AREA ��i�t}UAD ' <br /> TYPE '30 — <br /> (Mailing Address) FORMS <br /> GL 04 ��?� NOTES -- <br /> (City,S e,xlp Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitt)d) <br /> The unde , hereby applies for ermission to exca ate,construct and/or otherwise encroach on County Highway Right�of• ay o <br /> the side of 7z o.�r , d/ —approximate) _ <br /> of v y 4!e-LL-.!feedmlle <br /> by performing the following work(description of work); <br /> AA <br /> OL Zol <br /> r r o <br /> WC .n <br /> Work will commencftn ora ut _for an mately <br /> itl44 <br /> ��'ro� days. <br /> I,the undersigned,certify that I am the owner�of the re peuc, ve pproperty, �r am qualified to repres represent the 04 owner and agree to do the <br /> work described above In accordance with the rules and regulations S n Joaquin County and subject to inspection and approval, <br /> ti atnro of Applicant•TItIe <br /> Dete <br /> �wwnuer ,aianwrnw.na wwu <br />