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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# aa,�V, (p'? REF <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO /00/4z. DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ---,"n- <br /> AREA <br /> QUAD A11,0 <br /> TYPE <br /> (Mailing Address) FORMS <br /> _ <br /> 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 to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about :7 for approximately 1 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 /> 'SigAatu LWApplicant-Title Date <br /> J <br /> E:WUB SVWKVAASTERPS%ENCR0ACHMENT PERMIT APPUCATIONDOC (01108) <br />