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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date --- ---� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> �J� _ <br /> Department of Public Works APN <br /> CR# <br /> EXP.DATE d <br /> i L ta L rt.i- GA TO <br /> (Applicant NamSTREET p 1 DRIVEWAYS: <br /> AREA <br /> TYPE QUAD CG _ <br /> (Mailing Ad ess) FORMS <br /> J' <br /> NOTES <br /> / I <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> I Sketch(Detailed plans may be submitted} <br /> I I <br /> The un ersigned hereby applies for permission to excavate, construct and/or otherwise encroach <br /> �n County Highw Right-of-Way on <br /> thed_, -# side of Z 4.,, . <br /> of C . . I, , . approximately /1 =smile <br /> -`' by performing the following work(description of work): <br /> Work will commence on or about_ t~ - /`7 <br /> far approximately_ / days. <br /> I,the undersigned,certify that I am the owner of the respective property, <br /> work described above in a�eb"rd rice with the rules and regulations of San Jo quip oalifidunty and to rsubject to inspect on and approent the owner and ree toova e <br /> ��Si�gna re of Applicant-Title —�- <br />