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APPUCATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date tlt//l,//c.. <br />OFFICE USE ONLY <br />To:San Joaquin County <br />Department of Public Works <br />(,"15 <br />(Applicant Name) <br />4cJ.4o Wpf-L J'J <br />(Mailing Address) <br />~Q.~qSLo<f <br />(City,State,Zip Code) <br />!lOr ->1<'-11(.7 <br />(Area Code -Telephone Number) <br />J08# <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS:•• <br />• <br />Sketch (Detailed plans may be submitted) <br />J <br />The undersigned hereby applies for permission to excavate,cons\ruct and/or otherwise encroach on County Highway Right-of-Way on <br />the Fe;,'*side of 6:+vt ••.,,,i\.S ~J::approximately 7 0 ~llVmile Sg.4l <br />of F 6 sf ,":ci::1~h ,by performing the following work (description of work):X...:rIA ;>btll 2 -">2 {b _--J_QVI G-e....RUe •.•.;- <br />days. <br />Cfl./Ifo/I6.Date <br />for approXimatelyWorkwillcommenceonoraboutDl..f1 <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 ve ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval.