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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4 i <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB �• 5�-� >8 REF# <br /> aPN <br /> — � EXP.DATE �jt �,s-- r�, cR# <br /> VALID <br /> (Applicant Name) T /5- DRIVEWAYS: <br /> STREET <br /> `' AREA QUAD <br /> TYPE ��} <br /> (Mailing Address) <br /> FORMS <br /> a? NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number)i <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way the �-- side of <br /> of — 9 y ght of-Wa on <br /> approximately I�, feet/mile —� y_ <br /> _ { by performing the following work(description of work): <br /> eL <br /> Work will commence on or about "�' � ,° <br /> i, <br /> for approximately <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 /> days. <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and a <br /> -; pproval. <br /> Signature of Applicant-TitleuIz- <br /> i 1 <br /> p to <br /> E:IPUU-SV.WKUIV,STER.PSIcNCROACHMEITP,-moi N.7 gpF�JCp,TIONDCC (01/OBj <br />