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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 /> EXP.DATE 60 <br /> C & <br /> VALID 1Z TO 0,0,6 OLC,Cob DRIVEWAYS: <br /> (Applicant Name) SRM M)ak. <br /> AREA UAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 7 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ' ,/, side of - " ' / ' <br /> / Yt-LL -�-� - - I <br /> _Z/_ -4 approximately fee <br /> of yffiile�_ _ <br /> by performing the following work(desdnp*on of work): <br /> 4 <br /> Work wlll comm -about Z <br /> ence on <br /> _114L�Lir'_44�lfol r approximately 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 /> ficant-Title Date <br /> Signature of PAII5 <br /> PUS-SV WMMAS TER`b'TNCRGACKMFNT PERMIT APP(-]CATION COC I�,I'M <br />