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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datei -0FFICE USE ONLY <br /> -- -- ---- ----- <br /> To: San Joaquin County JOB# _ REF <br /> Department of Public Works APN CR# <br /> t EXP, DATE ,. _ • -, »' -- ----- <br /> _--- --: - -- _ >' - VALID `7.. _ ^ TO - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA ►€• OU , w <br /> � AD <br /> TYPE <br /> (Mailing Address) FORMS - r _ <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> ------------------ -- <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for,permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wav on <br /> the „ ° --side of approximately_ &c--, 'feet/mile <br /> of -f,..� _;; *,r4r, _ ,: ,,r; ,, , :z , .�.y �:.t j ; z by performing the following work-(dtscripti <br /> 9 on of work): <br /> t <br /> _ r <br /> Work will commence on or about - f for approximately _ days. <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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title �_ Date <br />