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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB <br /> Department of Public Works APN REP ------------- <br /> CR <br /> EXP. DAT 1 157 It <br /> (Applicant-Name) VALID 7. o 0 STREET DR1VXwAYS: <br /> AREA QLTAD <br /> TYPE—,tz*W-A 8E of e <br /> (Wailing Address) <br /> FORMS <br /> NOTE <br /> ---------- <br /> (City, State, ZiP Code) <br /> ........................................... ------- <br /> (Area Code - Telephone Number) <br /> Sketch 11 (Detailed plans may be submitted) <br /> 4- <br /> 4,1 <br /> The undersigned hereby <br /> otherwise encroach on applies for permission to excavate; construct and/or <br /> County IfighwayRight-of-Way on <br /> the <br /> -- _ side <br /> of . ,7• — approximately feee- <br /> following work7--------�0 <br /> (description Ofwork) - -7zct f{ by performing the <br /> /ZL/ I <br /> Work will commence on or about <br /> days. for approximately <br /> the undersigned certify that I am the owner of the respectiveproperty, <br /> qualified to represent the owner and agree to do the work described above inor am <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature Of Appy 46ant Title <br /> Date <br />