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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -7-- 2 Z- - OFFICE USE ONLY <br /> To: San Joaquin County JOB# ��(l, REF# <br /> Department of Public Works APN CR# <br /> l EXP. DATE +/"9OJO <br /> V11 r t (�\'v Ci L ��5 (y'uc-T Cy� VALID ?.o9 TO _�•4.XV0 DRIVEWAYS: <br /> (Applicant Name) STREET J e - <br /> AREA QUAD <br /> • r' G jC �::! TYPE -ALl�an/iYlEnil: <br /> (Mailing Address) FORMS <br /> NOTES <br /> I <br /> (City, State,Zip Code) <br /> & <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 by performing the following work(description of work): <br /> S C LA AVI-3 C3 3'z-Cj, <br /> tti' l ...� 5a' Y�Gr'��G�,! � � � 1".'"�f 7— 2 -7— (i' <br /> Work will commence on or about for approximately 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-Titles Date <br /> V.FORMS E TEMlLATES�iNt7i0ACHMENT PERMIT APPLIOATION.dec X0&08) <br />