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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> I <br /> EXP.DATE i2v <br /> VALIDTO /�z 11,116, DRIVEWAYS: <br /> (ApplicantName) STREET <br /> AREAQUAD <br /> lI ca. TYPE <br /> (mailing Address) FORMS <br /> 41c NOTES <br /> (City,State, Lip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct an�/or otherwise encroach on County Highway Right-of-Way on <br /> the <br /> by performing the following work(description of­Fwork� <br /> -j. <br /> Work will commence on or a—bo—ut-7 <br /> -L. for approximately days. <br /> 1,the undersigned, certify that I am the owner of the respective property,or am qualified to represent the omver 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 /> n ure of Applicant-Title <br /> ilv� `4" '( PERMIT <br /> I " � Date <br /> L/ 12 <br /> 1 C, <br /> E'PUB-SVWK-1111 I."1".Al".11T 11�.1T11U11TK'1 DDC-P1108) <br />