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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C -- ;( :{ /)(r° <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works, f® REF# <br /> APN CR# <br /> EXP.DATE f o <br /> VALID .j3, TO <br /> (Applica t Name) T o DRIVEWAYS: <br /> STREETAREA x <br /> -t,(PE QUAD — /i <br /> (Mailing Address) FORMS SS dui <br /> NOTES <br /> (City,State,Zip Code) <br /> ", : .. 1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1m i <br /> The uodeisigned hereby applies for permissionexcav <br /> the side ,construct and/or otherwise enc ch on County H' Right-of-Way on <br /> -, C3r, <br /> f ile <br /> of approximately <br /> by performing the following work(description of work): <br /> Work will commence on or about <br /> for approximately <br /> t, the undersigned,certify that I am the owner of the respective Property, days. <br /> work described above in accprdance with the rules and regulations of San Joaquin to represent the owner and agree to do the <br /> '� + isubject to inspection and approval. <br /> Signature of A <br /> Date <br /> EIPUBSVW;IMISiER.PVZ'4CROACHMEM- r; <br /> PEPtATAJCAION.000 (01178) <br />