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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> I � <br /> To: San Joaquin County JOB# flo REF# — <br /> Department of Public Works APN CR# <br /> c r i, . -- VALID ATE -- d� DG d0 ^ DRIVEWAYS: <br /> (Ap cant Name) - W Af: =SAk <br /> G � IZ v ad <br /> i <br /> AREAQUAD <br /> TYPE Ots - <br /> (Mailing Address) I FORMS �- <br /> r" NOTES — <br /> I <br /> (City,State Zip Code) ' `f — <br /> .' f <br /> (Area Telephone Number) <br /> ( P <br /> Sketch(Detailed plans may be submitted) <br /> I ' <br /> I <br /> I <br /> I <br /> i <br /> I <br /> i <br /> I <br /> I i <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway R�ht-of-Way on <br /> the„ _J' -side of approximately— ' ' = _J_ fee mif <br /> of__ =_ _ _ by performing the following work(description of work): <br /> Work will commence on or about ', r 1-_ _�_ _ _f /for,a proximately , 17 ,_� .Fdays. <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 /> Signat re of A(olicant-Title e -- <br /> _'PUB 9V WKMASTPRPSENCROAt:H'!ENT KRMIT APP!KATION w <br />