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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department ofPublic Works <br /> VALID )a TO DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA MAPM4A QUAD 5�_c <br /> YPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission tnexcavate, construct and/or otherwise encroach on County Highway Right-of-Way <br /> side of _7 <br /> approximately_. k��& feet/mile <br /> of by performing the following work(description of work) <br /> Work will commence on or about 1 A J6 for approximately days—. <br /> |.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 tninspection and approval. <br /> Sighature of Applicant-Title Date <br /> E IPU4 SVWKIMASTExnIENCROACHIMcNT PFRL41TAPPLICATION DOC *.M` <br />