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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _--- OFFICE USE ONLY - <br /> To: San Joac€uin County JOB# � REF 4 <br /> Departm6 rt of Public Works iAPN -` <br /> CR <br /> EXP.DATE 2 ---- <br /> ",e( r t,_ VALID fd TO DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREAQU. --- - <br /> AD <br /> _ TYPE <br /> (Mailing Address) I FORMS SS l✓a.✓ ——-- <br /> NOTES <br /> -((ity,State,Zip Code) ---- _ <br /> (Area Code-Telephone Number) <br /> Sketch-,Detailed r ans may be submitted) _ <br /> - <br /> f r - <br /> i <br /> • <br /> The undersigned he•eby applies for permission to ex vgte,construct and/or otherwise encroach on County Highway Right-of-Way or: <br /> tAe_ — side of `., $ YrS approximatel ""- , <br /> Y <br /> feet/mile <br /> u <br /> by performing the following work(description of work): <br /> Work will commence on or about fora <br /> pproximately <br /> --_—days. <br /> the undersigned,cartify 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 accordancedth the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title � � -- <br /> Date <br /> t+Uu:'t:TW.:JTER+S'EhiHUM:l41'1'�(:Hhfl'4W.,;;,'N:•i'..](: ;1;.9.; <br />