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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date Jy e OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> 7— <br /> EXP. DATE <br /> /{rte VALID -178 TO j'�-I�4e DRIVEWAYS: <br /> (Applicant Name) STREET Xl" OAle- <br /> AREA (QUAD 6:1, <br /> TYPE /IC/' , l�lO <br /> (Mailing Address) FORMS <br /> G�- NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> sys - 6 61 �sz9 <br /> � D <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the si e of <br /> approximately eemile <br /> of by performing the <br /> f llowing work (description of work) : -� <br /> Work will commence on or about for approximately <br /> 6 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 /> inspection and approval. <br /> Signature of Applicant - Title Date <br />