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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 <br /> CR# <br /> EXP.DATE <br /> VALID 19' T DRIVEWAYS: <br /> (Applicant Name) STREET 0 <br /> 195TA V>. <br /> rv–� - <br /> AREA ST<k--k='P.J QUAD <br /> TYPE <br /> :t'e <br /> (Mailing Addreis) FORMS <br /> NOTES <br /> ES <br /> Kk t7 (C <br /> (City,—State,Zip Code) <br /> C L <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> L <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise <br /> the side of the on County Highway Right-of-Way on <br /> of approximately.__ 'y, I feettmile <br /> by performing the following work(descriptio— <br /> n of work): <br /> f 4It, MA L A� <br /> 'Y <br /> WO—'k will commence on or about for approximately <br /> 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 /> bignAure of Applica6l-Title Date <br /> E:U'IJB-SV WKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01M) <br />