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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date -0,3= p-I-- _ <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works t REF# <br /> APN CR# -- <br /> ' EXP.DATE <br /> (Applicant Name) VALID co 4 Tp STREET #o,_ 2oro DRIVEWAYS: <br /> '�j5 � y <br /> r AREA SiaG QUAD <br /> (Mailing Address) / TYPE '� ► o1JLy <br /> FORMS <br /> � � /�-► NOTES ' <br /> (C ,State,ZIP Code) ---- -- <br /> �cde &elepho�neNurnber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission o excavate,construct and/or otherwise encroach on County feetlmile <br /> Highway Right-of-W <br /> the _side of <br /> Of approximately- /p 50 on- <br /> by performing a following work(description of work): <br /> l 9 � <br /> ------------ <br /> - -_ -- <br /> Work will commence on or about <br /> — �� for approximately_ —�-- <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 t e <br /> days. <br /> work described ve' ccordance with the rules and regulations of San Joaquin County and subject to inspection and ap roval <br /> p <br /> lure _ } _ 0 <br /> Applica -Title <br /> Dat' —-- <br /> []PUBSY.1V76µ�s p , OINEW PFJ tsyaMfl1CJ47101tam RIAs} <br />