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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# _ �'` REF <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 0 DRIVEWAYS: <br /> (Applicant Name) STREETAREA <br /> ✓E. <br /> � LC:a _ TYPE aCleXrt1 QUAD __ <br /> l�Lc2�wstE1�, <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the , side of_ DAA_ ' approximately 0- Z feet/ <br /> of � T_y� by performing the following work(description of work): <br /> 32�64 � --Q ` —� <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 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 /> E1PUO-SV.WKIMASTER.PS1ENCROACHMENi PERIA!TAPPIJCATION.DCC pii,)aj <br />