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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> .. OFFICE USE ONLY <br /> Date <br /> OB# J���' "�__ REF# <br /> To: San Joaquin County JOB <br /> Department of Public Works APN -- <br /> EXP.DATE } r t"•- DRIVEWAYS: <br /> VALID iZ 1S �� — TO r� <br /> (F�pplicant Name) STREETS M A P �✓ <br /> AREA QUAD <br /> TYPE <br /> (1111ailing Address) FORMS ';L-, -0 — <br /> �a 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 Highwa Right-of-Way on <br /> the aS ;ide of �£,1- i"v'R-- approximately_ ° <br /> of f1 A f_ 'eek-� by performing the following work escription of work): <br /> 0 <br /> Work will commence an or about <br /> f for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qua ICo tl to and subject to inspection aresent the owner and nd d aree to do al e <br /> work described above in accordance with the rules and regulations of San q Y <br /> rr e , <br /> Signature Applicant-Title -�;r � <br /> D to <br /> E.1PJ3-SVWMMASTERP51ENCROACHMEE!pFP.t.BTAPPLICATiON.000 (01108) <br />