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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> � <br /> Date 4- OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department ofPublic Works <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> ' <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 on <br /> side of approximately <br /> of <br /> by performing the followi--o—(�_e_;cription of work): <br /> Work will commence on or about -for approximately days. <br /> ithe undersigned, oortify that|anthe owner Uftho � property,or8mqual�SUtorepresent the owner and agree todothe <br /> work d000hbadabove inaccordance with the rules and regulations ofSan Joaquin County and subject toinspection and approval. <br /> ^°�0]ZP �7 <br /> _~~.,,MA,.~.~T-'i,~OA===,ERU.^PP"mmvu0�w,mw <br />