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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 f�dDD$ REF# <br /> APN CR# <br /> EXP.DATE <br /> VALID <br /> (Applicant Name) STREET I?. TO DRIVEWAYS: <br /> AREA <br /> TYPEQUAD <br /> ,yp p C <br /> (Mailing Address) FORMS ' <br /> NOTES <br /> (City, State,Zip Code) 'e'� 4c `- <br /> L/S>rlk� ptl S S Zif X <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> G. 'ery! <br /> The undersigned hereby applies for permission to excavate,=approximately <br /> /or otherwi•seyencroa h on County Highwa Right-of-Wayon <br /> the t, side=of <br /> of �.� w'`' 4 <br /> by performing the following work(description of work): <br /> H)P <br /> Work will commence on or about <br /> for approximately <br /> 1,the undersigned, certify that I am the owner of the respective ro days <br /> work described above in accordance with the rules and regulations of San JoaquinCounty represent the owner tioi and to da the <br /> inspection and approval: <br /> ,tom--;'/� f/` � / :J�• � _ ,1 <br /> Signature (1 -3 <br /> of-Applicant-Title l <br /> Date <br /> E:IPUB-SY.WKVdASTER.P-%ENCROACHMENTPERMITAPPLICATION.DOC (01M) <br />