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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /,. OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> j EXP.DATE G <br /> L - VALID 0 2. _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> r� <br /> AREA �'yac.rrz�J QUAD A/.S <br /> TYPE -Al <br /> (Mailing Address) FORMS S' lvrtJ <br /> NOTES <br /> t <br /> (C ty,State,Zip Code) <br /> Area Code-Telephone-..Number) ---- <br /> Sketch(Detailed plans may be submitted) <br /> n <br /> l ttlJ <br /> !,x " ? 3 ,I <br /> The un si ned hereby applies fo permission to excavaAff ns uct and/or otherwise encroac on aun Highway Right-of-Way on <br /> the side o approximately <br /> by performing the following work(description of work): <br /> 9-1 VIA wt i tie R-- �1 <br /> Work will commence on or about_ for approximately days. <br /> I,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 /> ignature ofApplirdank Jntlek ate <br /> E 1PUB-S'/WNIMASTER PSIENCROACHMENT PERMIT APPLICATION DO- (01/08) <br />