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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date a G OFFICE USE ONLY <br /> To: San Joaquin County JOB# -73C2f�jq__-;z, — REF g <br /> Department of Public Works APN _- _.-- -- _ CR# —! <br /> PC-VN ]✓J <br /> EXP. DRIVEWAYS: <br /> DATE _ 'aOl� <br /> j\, VALID �a t U TO <br /> 1� : 3� <br /> (Applicant Name) STREET - ►�����. St <br /> �-y <br /> AREA S�c�Gh��vw QUAD sS <br /> � CO L TYPE �rewC4L �bY� f <br /> (Mailing Address) FORMS ES/ W w <br /> i NOTES <br /> (City, State, Zip Code) <br /> LA-i+. LA ll, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> i <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway R ght-of-Way on <br /> the t771i"1 s e�cf �. �tX-1 approx mate y <br /> of by performing the followiiez\ng work(description of work): <br /> i XLkLA <br /> tXl r _ <br /> Work will commence on or about for a,proximately days. <br /> I, the undersigned, certify that 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 ,,vith the ruies and regulations of San Joaquin County and subect to inspection and approval. <br /> F xy!' '0 <br /> J . <br /> Date <br /> Signature of Applicant T' le <br /> v'FORuS a TcM?tATES'E4,CROAGHMEr;T FEnta!7 APP IGATION.;c 1rPJM <br />