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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date );s't OFFICE USE ONLY <br /> — i <br /> To: San Joaquin County JOB# ! REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 20ATO – DRIVEWAYS: <br /> (Applicant Name) — STREET <br /> AREA T ya QUAD <br /> v 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 /> f <br /> t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the foiloWng work(description of work): <br /> C=7'AnU <br /> YE [r <br /> .� <br /> } <br /> Work vwll commeAce on or about L.Ae,',-L,4 4 �F€� for approximately days. <br /> 1,the undersigned certify that!am the owner of the respective property,or am qualified to represent the owner'and agree to do the <br /> work described above in accordance with the niles and regulations of San Joaquin County and subject to inspection and approval. <br /> -Y!!/- <br /> 79"ture of Applicant-Title Date <br /> EPUB.N.WKW$1FRPSENCROAC-N#r�ATP-40AI,TAPP_ICATON` OC.1,M <br />