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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> AV OFFICE USE ONLY <br /> Date <br /> To: San Joaquin County <br /> Department ofPublic Works <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET AJI�PJZA AX. <br /> AREA QUAD <br /> ee7- z./ / 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 |i for i i to excavate, constructand/or otherwise h on County Highwpy Right-of-Way <br /> the I-Y6�"57 side of approximately feamile el <br /> Of by performing the following work(description of work): <br /> 57 <br /> Work will commence on or about 7-&10 for approximately days. <br /> | the d iod certifythat| am the owner of the respective property, oramqualified t)represent the owner and agree todothe <br /> work described above in accordance,w6 the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> '~/ . <br /> t�lgnature of Applicant-Title Date <br /> E PUB SV vWMASTER PMENCROACHMENT PERMIT APPLICATION DOC (01108) <br />