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PLEASE PRINT- APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> --------- OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works <br /> APN REF# <br /> EXP.DATE --------— CR# <br /> 12_ te0la <br /> C <br /> (Applicant Name) VALID <br /> STREET TO _1Z.j.0S DRIVEWAYS: <br /> AREA -71e.4 QUAD <br /> (Mailing Address) TYPE - <br /> FORMS 4VkQ <br /> NOTES <br /> (City, State,ZipCode—)(Area Code ---- <br /> Telephhone Number) - <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-Way on <br /> by performingrmin=gg <br /> the <br /> sid"f <br /> of <br /> I-/- ---- approximately 1. 7) <br /> the following work(description(des' <br /> F It-, <br /> crilption of work): <br /> 14 <br /> r <br /> VVOFK Will commence on or about <br /> 1, the undersigned, certify <br /> approximately------- ------ days. <br /> rtify 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 <br /> E!PUS-SVWKMASTER PSIENCROACHMENT PERMIT APPt1CAT!CN 00C (01,08) Date <br />