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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB#APIV e'bt"Z- i REF n <br /> EXP. DATEF CR# <br /> `�"� <br /> (Applicant Name VALID z TO �/,, <br /> STREET _� -_� _------ -- DRIVEWAYS: <br /> AREA <br /> (Mailing Address) TYPE QUAD`��-i <br /> FORMS , <br /> NOTES — --- <br /> (City, State,Zip Code) <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 <br /> the =� . .; side of <br /> approximately <br /> of % '' on County Highway Right-of-Way on <br /> ie ,_�, <br /> by performing the tollowifeetfng work (description of k): <br /> y <br /> -------------- <br /> :i. <br /> Work will commence onor about <br /> I, the undersigned, certify that I am the owner of the res for approximately <br /> days. <br /> pective 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 Count and <br /> • y subject to inspection and approval. <br /> Signature of Applicant-Title <br /> E:"U8-SV.WK4IASTERP5'T-%CRCACHN,ENT PERMIT APPLICATION.00C (01,09j Date <br />