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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date E , OFFICE USE ONLY <br /> To: San Joaquin County JOB# ���P�� � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE I–?BIZ <br /> VALID 5 2-R-2b TOCJ� DRIVEWAYS: <br /> (Applicant Namey STREET <br /> AREA k6C.%<J6v,-QUAD <br /> TYPE <br /> (Mailing Address) FORMS2� <br /> <:�A NOTES <br /> (City,State, Zip Code) <br /> �--Qtr -aG i`-I <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> G"! j e4- "q(TYS <br /> The undersigned hereby applies for,?ermjssion to qxcavate, construct and/or otherwise encroach on County Hig�h yRight-,of-Way on <br /> the�c side of � approximately 5 fmile WrAZTA <br /> of 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 /> Signature o pl ant-Title Date <br /> E:IPUBSV.WNIMASTERPSIENCROACHMENTPERMRAPPLICATION.DOC (01M) <br />