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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z_ OFFICE USE ONLY <br /> To: San Joaquin County JOB# //0v0:5L REF# <br /> Department of Public Works APN CR# <br /> r_ EXP. DATE <br /> VALID 6- /L1 15;// <br /> ,5/' 2- DRIVEWAYS: <br /> (Applicant Name) STREET c ' <br /> AREA QUAD AJE ' <br /> TYPE PP Va e- Stq <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �11 <br /> i <br /> Z <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately? I / feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about for approximately f 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 ac rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title �—'� Date <br /> E%PU%SV WAWUSTERPS%ENCROACHMENT PFUT APPLICATION DOC (DIM) <br />