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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t�) '' i OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 4 l< <br /> VALID 4bbl to DRIVEWAYS: <br /> (Applicant Name) STREET Xkg., I <br /> AREAQUAD <br /> cat TYPE MIA419"90cr <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> i <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 Hig Right-of4ay on <br /> the side ofy P approximately 'I ti�' ile <br /> Of o�- - &- tr I , by performing the following work(description of work): <br /> Work will commence on or about y 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 /> Signature of Applicant-Title Date <br /> E'.IPUB-SV.WKNASTER.PSIENCROACHMENT PERMIT APPLICATION.00C (01108) <br />