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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ;2 I'T-1 I i <br /> T OFFICE USE ONLY <br /> To: San Joaquin County JOB# �e�'f REF# <br /> Department of Public Works APN <br /> CR# <br /> EXP.DATE ` if <br /> B'0' <br /> pli, ) VALID 0 / DRIVEWAYS: <br /> STREET j,rp I <br /> 1AREAQUAD <br /> TYPE S <br /> (Mailing Address;) FORMS 21 t <br /> _ NOTES <br /> (City,State,Zip Code) <br /> ) <br /> (Area Code-Telephone hlumber) _ <br /> 7Sketcled plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side <br /> of LgS A-Ack � ' approximately. feet/mile :J <br /> i �V T by performing the following work(description of work): <br /> Work will commence on or about i 3 r for approximatelyU--- <br /> d <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 <br /> Date — <br /> E:IPUB-SY.WMMASTEF PSIENCROACMMENT PERMIT APPLICATION DOC (01108) <br />