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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 3 r, <br /> Date - -�, ; <br /> i � � OFFICE USE ONLY <br /> To: San Joaquin County JOB# :007 f'''�� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO / ' Jj DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAr=jr 2rt QUAD <br /> TYPE �- <br /> (Mailing Address),,--�� FORMS <br /> V"N-1.-C - -. s'Zy L �� NOTES <br /> - <br /> (City,State,Zip Code) <br /> 1--cCA `D a C.'� � -,�a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> it a-C <br /> The undersignedherebyapplies for permission to xcavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the <br /> \\ side of e �r''a. �9 approximately PiN Y feet/mile <br /> of <br /> by performing the following work(description of work <br /> Si ,fit L <br /> Work will commence on or about i for approximately days. <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 Date <br /> EXPU&SV.WKVAASTEP PSOCROAMAENT PERMRAPRJCATION.DOC(Ot%) <br />