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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 /> AREA 11W,4?!PRW QUAD <br /> io <br /> -VI-enele VALID fol DRIVEWAYS: <br /> (Applicant Name) STREET p <br /> TYPE <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 to excavate, construct and/or otherwise encroach on County Highway Right-of-Way <br /> of <br /> by performing the following work(description of work): <br /> Work will commence on or about for approximately days. <br /> | the nramqualified torepresent the owner and agree hodothe <br /> work described above,,jrlj�oordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ��Jnatu A7pplicant Title Date <br /> � <br />