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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1N11"\'(k_1'\�C`V-1\ It OFFICE USE ONLY <br /> To: San Joaquin County JOB# '�,� ~ "j ..l`l REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE r ' <br /> VALID — <br /> )� DRIVEWAYS: <br /> (Applicant Name) STREET Sag _ <br /> AREA QUAD AdIs <br /> TYPE S t <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> y� <br /> g <br /> The un ersigned hereby applies for permissinn to excavate,construct and/or otherwise encroach on County High y R�ht-of-Way on <br /> the _side of_ ,G �, approximately / <br /> of /A47rA'"W, 4D ,by performing the following work(description of work): <br /> Work will commence on or about for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am quaffed 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 /> E:ft8-SV.WMMASTERPSte4CRDACHMENTPEFWAPPUCATION.DOC (OMIB) <br />