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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 22000 REF# <br /> Department of Public Works <br /> APN <br /> CR# <br /> EXP. DATE /.0 � /%- <br /> VALID 17 2-4" e 0 1 Z' DRIVE <br /> A <br /> (Applicant Name) STREET WAYS:l <br /> AREA QUAD CC, <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Co—de-Telephone Number) <br /> Sketch—(Detailed plans may be submitted) <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 <br /> of approximately feet/mile <br /> by performing the following work(description of—work). <br /> 2, <br /> Work will commence on or about 4,,,,. <br /> 4 �41 ocl": for approximately. days. <br /> 1, 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 /> Id el-t <br /> ature <br /> Siof Applicant <br /> I ture -Title V —Date <br /> -- <br /> E:ft8-SV.WKVAASTEP PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />