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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB# if F# <br /> Department of Public Works APN REF <br /> # <br /> EXP.DATE / y- <br /> VALID zA - TO / DRIVEWAYS: <br /> ( pplicant Name) STREET <br /> D, <br /> AREA �TTJ_ / QUAD <br /> �$$ k-W t" , TYPE <br /> (Mailing Address) FORMS <br /> 5 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 t xcavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the side of a roximately fee ile <br /> of 1 t- W wt y performing the following work( escription of work): <br /> e c_ <br /> Work will commence on or about Izec,. <br /> i;L0>X x for approximately dY s. <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 rues and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature Applicant-Title Dat <br /> E:IPUBSV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />