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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - <br /> OFFICE USE ONLY <br /> To: San Joaquin County [APN <br /> OB# <br /> Department of Public Works 7 ��Z g REF# <br /> CR# <br /> £ EXP.DATE <br /> (Applicant Name) VALIDSTREET 0 �'�� DRIVEWAYS: <br /> 1 � Is_ - AREA <br /> ��O � `� ' � TYPE �l6tk'TLA✓ Q AD A- <br /> `^ r (Mailing Address) FORMS <br /> V V CX Qk1 <br /> CCA- LJ OTES <br /> Q (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 30 � e <br /> thee undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High�3y Right-of-Way on <br /> side oftTusp.C� �L a <br /> of L ---�- approximately I bo /�fe mile <br /> (j r by performing the following work(description of work): <br /> Work will commence on or about _ L t <br /> for approximately-- I-) <br /> 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 <br /> Date <br /> BWU&SV.WgMASTER PSIENCROACHMENT PERMIT APPLICATION DOC iOvoe) <br />