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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' —`1, ( OFFICE USE ONLY <br /> To: San Joaquin County JOB# //000S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> L I u(�E N 'vtnLr VALID 121q111 0 IA DRIVEWAYS: <br /> (Applicant Name) STREET ,c - <br /> V tt S OL A40- I AREA QUAD <br /> IF-I•0---y -1j 1 (= c - TYPE i21P ,eoAD G'GoSU,�6 <br /> (Mailing Address) FORMS <br /> NOTES <br /> 9S- , <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> S'E CT l o y T <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -,q+ side-of LAkc--S or— reoA-I—i S approximately feet/mile <br /> of , by performing the following work(description of work): <br /> YIA )) CJ---My-1fL 3 I �o t \ <br /> Work will commence on or about ��C—ur t3tn 3 , o I for approximately '3' z Nu d <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 /> ignature of Applicant-Title Date <br /> E:1PUB-SVOKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC )01108) <br />