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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , -- � � OFFICE USE ONLY <br /> z <br /> To: San Joaquin County JOB# / j REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID p ,die TO 1/ 0 9 DRIVEWAYS: <br /> (Applicant Name) STREET wcr — ' <br /> AREA QUAD ' <br /> TYPE 6rff/� ld5 � <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) ,Ay' <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) / <br /> �`�,ti�J � � ��lrlG'OM D+A✓A' IC-G✓It td� <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 .�� ,.�,;,� � ,� 1; �, T;.,� ,� �4,, .�, voSh by performing the following work(description of work): <br /> Work will commence on or about 21 --bQ/er'h- for approximately days. <br /> I%ooeo-' <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 /> F <br /> Signat-4re 4f Applicant-Title Date <br /> YSFORAS;TGMPL47ES'E!1CROA.C.N1&g7 PER1A!TP.PPLICATICNc,c!O AI <br />