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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � . - '�� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# W <br /> Department of Public Works -CFP-110(,0,5— REF# <br /> _ APN CR# <br /> EXP.DATE ( 20!I <br /> VALID $-?q-2,,tl TO q•. 2v !I DRIVEWAYS: <br /> (Applicant Name) STREET <br /> r Z r <br /> AREA UADf2 QUAD <br /> (Mailing Address TYPE —4 <br /> FORMS <br /> NOTES <br /> ,City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> po g1 z�/�r <br /> The undighereby applies for ermission to exca�vate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the _side of /�lF,rcf� Gii_ <br /> of approximately feet/mile <br /> ��, n� G«S by performing the_fo)lowingyuork(description of work): <br /> Work will commence on or about <br /> for approximately 0/7 L 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 /> E:IPUBSV.WKWIASTER.PStENCROA(NMENTPFRMITAPPUCATION.DOC (01/06) <br />