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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# 00 REF# <br /> APN <br /> EXP.DATE CR# <br /> (Applicant Name) VALID 4 <br /> STREET O 19, DRIVEWAYS: <br /> G v. AREA <br /> I_!k �QUAD <br /> (Mailing Address) TYPE 'Races 1-tp <br /> '� <br /> FORMS r,--�'tz '--RA�68 <br /> NOTES ---------- <br /> (City, State,Zip Code) <br /> (Area Code--Telephone—Number) <br /> — <br /> Sketch(Detailed Plans may be submitted) <br /> T <br /> The undersigned hereby applies for Permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 1� <br /> side of <br /> approximately <br /> 25�1 —i <br /> performing he following work'(description— <br /> by perfo —ng-Q�follow�, �/ree6le <br /> following <br /> Ofwork): <br /> < <br /> Work will commence on or about for approximately ------ <br /> 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 <br /> work described above in accordance with the rules and regulations of San Joaquin C do the <br /> lunty and subject to inspection and approval. <br /> Signature Of-ApP1'1c6h-t----Title <br />'PU&SVWK!MAS7E <br /> ^"SEWCROACHMENTPE,'RM17A--L,CA—i0N.000 �;o Date <br />