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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date :(. � J <br /> OFFICE USE ONLY <br /> To: San Joaquin County [AP <br /> # �,� REF# _ <br /> Department of Public Works CR# <br /> t AJ ALN73 .DATE _ fid' /S.G► <br /> VALID •O TO ,�/s o8 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 573c&Ttw1/ QUAD <br /> TYPE -MMP. ROA1> C .vs 46 <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,2ip Code) <br /> (Area Code-Telephone 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 /> of- <br /> approximate/ <br /> by performing the following rk(description of work): <br /> U <br /> Work will commence on or about lb a r),, -tv I <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 /> 1 ' <br /> Si atu�e of Applicant-Title — ~' <br /> Date <br /> E:IPUBSV.WKWASTERPSIENCROACHMENTPERMITAPPLICATION.DDC (01/08) <br />