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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San oaquin County JOB# 73,00 <br /> Department of Public Works REF# <br /> APN CR# <br /> EXP.DATE y <br /> (Applicant Name) <br /> VALID 1Z TO I jL DRIVEWAYS: <br /> STREET D. <br /> * <br /> AREA QUAD <br /> TYPE <br /> fling Address) FORMS <br /> w •z <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> p�wcA <br /> K)D -01 :e <br /> + cot - <br /> 5e� <br /> 4i - <br /> r � <br /> The undersigned hereby appli for ermi i n to excavate, construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the side of <br /> of , approximately " mile <br /> a by perfor 'ng the Ilowing work(d scription of work): <br /> iN <br /> :aV <br /> Work will commence on or about"��,-� ; <br /> L for approximately 2D 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 /> Signatu f Applicant itle --is l i--- <br /> Date <br /> ;EATUB-SM-MMASTERPMENC ACHMENTPERMITAPPL ATION.DOC (OW8) <br />