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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ` <br /> Date `��31 (' — (v cky r\ la 1 l` OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE3M ki 4va t 10 <br /> tY)Cl7 n mUINAL VALID / ogo/a-ow O X20/ DRIVEWAYS: <br /> (Applicant N e) �jOt�P,0h STREET jai/X447- Dat. ' <br /> � r1 ii (( AREA ,t�6f/ QUAD LV ' <br /> .V LAI 10144 TYPE T/Yl� �oAJ� CLoSu.� <br /> (Mailing Address) FORMS s <br /> NOTES <br /> grs2loq <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may gbe submitted) <br /> . fY&p <br /> I <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 "Du- Y� ,by performing the following work(description of work): <br /> �Y� I��J Panrta <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 /> � l <br /> sigOftde o Applicant-Titl Date <br /> UPUS-W. PMCROACMAENTPEAA"APPLICATIONAOC (011M <br />