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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date ~t//(,//(. <br />To:San Joaquin County <br />Department of Public Works <br />(c;.e <br />(Applicant Name) <br />4C14D Wl.If-LN <br />(Mailing Address) <br />~\lM Q.J-+QSL4'f <br />(City,State,Zip Code) <br />l./Olr->'(.-11,-7 <br />(Area Code -Telephone Number) <br />\ <br />OFFICE USE ONLY <br />JOB#7ZI2O$2.REF# <br />APN CR# <br />EXP.DATE 6-/$-lb <br />VAUD ,:tNh TO 6-tS-/6 DRIVEWAYS: <br />STREET Utl'tllh(• <br />AREA ~QUAD Sw • <br />TYPE • <br />FORMS SSLvW'R4ffNOTES <br />Sketch (Detailed plans may be submitted) <br />; <br />The undersigned hereby apPliesLfor permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ~side of ~vi •.approximately l'Il 0 (@1IImile ~ <br />of $,t414 t lA-ortt<I1V",,by performing the following work (description of work):~J:'""",-1.. <br />Work will commence on or about Oz.~for approximately days. <br />t:Y/ro/l {,.DatetureofApplicant-Title <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 describe ve I ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval.