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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, APN — 3� 52-2Z:) — REF# <br /> EXP.DATE CR <br /> # <br /> (Applicant Name) VALID --!!515b To <br /> STREET DRIVEWAYS: <br /> AREA <br /> TYPE -4mej�— QUAD <br /> (Mailing Adjre—ss,'F---- FORMS <br /> NOTES ------ <br /> (City, State,zip Code) � <br /> (Area Code-TelephoneN—um—be�r) — <br /> Sketch (Detailed plans may be su6mitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 45�dS7' side of <br /> approximately <br /> Of �feetllmile <br /> by performing the following work(description of work): <br /> ------------------- <br /> W—ork will commence on or—about ----------—-------- <br /> la <br /> for approximately <br /> y days. <br /> 1, the undersigned,certify that 1jam the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above ji <br /> C�' dance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title ; <br /> EWU!i <br /> TitlePV'(J!3 SVVWMASTERPSLENCROACH ME NT PEP,M11 APPIL I CAEONO()c (0 1/(i8) '-B—ate <br />