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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works REF# <br /> OFFICE <br /> JOB# ICE USE ONLY <br /> -Lo REF# <br /> PN CR# <br /> P CR# <br /> EXP. DATE <br /> V I20 <br /> VALID <br /> T T 0 '(t DRIVEWAYS: <br /> 0 Attl Ott DRIVEWAYS: <br /> 1P r). <br /> (Applicant Name) STREET <br /> QUAD <br /> JOB <br /> AREA <br /> TYPE <br /> (Mailing Address) FORMS <br /> 4- <br /> NOTES <br /> (City, State,Zip Code-) <br /> (Area Code-Telephone umber) <br /> Sketch(Detailed plans yam be <br /> submitted) <br /> Theundersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wgy on <br /> the side of <br /> approximately <br /> of O <br /> � mile Zrz <br /> by performing the following �-- -' <br /> work es <br /> cription of work): <br /> ------------ <br /> WA - <br /> 'o-rk will 1111 C 0 m m e-n-c e-o-n or about <br /> for approximately <br /> days. <br /> 1, the undersigned, certify that I am theowner of the respective Property, or am quald to represent the owner and agree to do the <br /> work described above in accordPn6e"with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of—Applicant Title � <br /> E IPUB-SV WKWASTER PS(ENCROACHWNU PERMI,AWLXV10N 90C IO1NgI Date <br />