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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 'A(sq OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 1 ,2. 0 L DRIVEWAYS: <br /> (Applicant Name) STREET 0,0 <br /> AREA - / QUAD <br /> TYPE .9GE <br /> (Mailing Address) FORMS --I,- <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C � �� �t <br /> FW <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way Right-of-Way on <br /> de of approximately t/mile <br /> of AA �,p.7 - , by performing the following work(description of work): <br /> Work will commence on or about for approximately 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 /> �igat�ureof!ApprOca���tle�� <br /> Date <br /> E:IPUBSV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />