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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date - ----- ----- -- --— <br /> OFFICE USE ONL v <br /> To San Joaquin County JOB# ^^t Rc.F <br /> Department of Public'Wc-Ks ---- <br /> APN CR r <br /> EXP. DATE <br /> - - -` - VALID = TO DRIVEWAYS: <br /> - --- _ <br /> (Applicant Name) STREET <br /> AREA S QUAD <br /> ---- ---- ---------- ------- _ TYPE _ <br /> (Mailing Address) FORMS <br /> I <br /> NOTES <br /> (City, State: Zip ) <br /> ..ode I <br /> (Area Code-Teleph&1e Number) <br /> Sketch (Detailed dans may be suomitted) --� <br /> i <br /> I � <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ -- side of approximately -- — - feet/mile <br /> — --- - <br /> _. by performing the following work(description of work): <br /> -- <br /> ` 1C'i <br /> Work will commence or or about_ - -- --- <br /> — _—=-- —= --for approximately —____ <br /> i, the undersigned. certify that am ,he owner of the respective property, or am qualified to represent the owner and agree to do the <br /> worK described above ;a accordancewith the rules and regulations of San Joaquin County and subject to 'inspection and approval. <br /> Signature of Applicant- Title --- <br /> Date <br />