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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEAS5 PRINT: <br /> e6 OFFICE USE ONLY <br /> Date <br /> To: San Joaquin Country JOB # //�/��� REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE �'�� <br /> s VALID TO�- `�`'; s�'" DRIVEWAYS <br /> V : <br /> (Applicant: Name) <br /> STREET j � <br /> AREA -slQUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> _ NOTE <br /> (City, State, Zip Code) <br /> (Ar/ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or of <br /> otherwise encroach on County Highway Right-of-Way on-the <br /> «.'a-r_ <br /> of by performing the <br /> following work (description of work) : <br /> Work will commence on or about /� � � 'C� for approximately <br /> days . <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 /> inspectior__and approval, <br /> -SignatureC -Z <br /> of Applicant - Title Date <br /> MASTdr..PS\FE+35 CPS.L (6/00) <br />