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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin Count g <br /> Y 0 # DO4� REF# <br /> Department of Public Works APN CR# _ <br /> _ EXP.DATE <br /> VALID 0 DRIVEWAYS: <br /> (Applicant Name) STREET ,q - <br /> AREAq/QUAD <br /> O, ?�' ,� c3/O TYPE . n5 <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) -- — <br /> (Area Code-Telephone Number) <br /> -- <br /> Sketch(Detailed plans may be submitted) ------ <br /> S 6.^ <br /> f <br /> Ii <br /> j <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 /> of by performing the following work(de <br /> scription of work): <br /> Work will commence on or about for approximately p- C 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 /> etuUB,SV WKIMASTER PSIENGRCACHMEh�."EP.M!T.APpIiCATIpN.000 �0'108'; <br />