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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB t 73.p05Z-(. REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID <br /> q 7 I la To OL rr to DRIVEWAYS:I <br /> (Applicant Name) STREET r MLY-� <br /> AREA Q �' <br /> :�L-o 2 C <br /> UAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> 7 L <br /> (City, State,Zip Code) <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 /> the side of approximately feeYmile <br /> by performing the following work(description of work): <br /> Work will commence on or about <br /> for approximately _days. <br /> 1,the undersigned,certify that I 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 rules and regulations of San Joaquin County and subject to inspection and approval. <br /> SignAu—re'of Applicant Title Date <br /> E�PUE SVWKWASTERPEVENCRDACHMENT PERMIT APPLICATION.100C (011081 <br />