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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S OFFICE IISS ONLY <br /> To: San Joaquin County JOB # �ag:5- REF # <br /> Department of Public Works APN CR # <br /> � ���/�+ EXP. DATE 1' Z <br /> ��Jy 17US�Ie/A� �:�./7 .J VALID V TO DRIVEWAYS: <br /> (Applicant Name) STREET t,�5 <br /> AREA — QUAD <br /> TYPE _ To :�' ,�/. <br /> (Mailing Adddrese) FORMS. <br /> NOTE <br /> (City,, State, ,Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby app7Lies for permission to,excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way os-the <br /> approximately <br /> of feet/mile <br /> followingwork (description of work) : by per€orming the <br /> -P <br /> Work will commence on or'about <br /> days for approximately <br /> I, the undersigned certify. that I am the owner' of the respective property, or am <br /> qualified to represent. the owner and .agree to do .the work described above in <br /> accordance with the rules :regulations of San Joaquin County and subject to <br /> inspection and approval - <br /> D <br /> Signatu of Applicant Title Date <br /> WISTSR.PS\FESS®L (6/00) <br />