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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 67 <br /> REF# <br /> [A <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> 4, <br /> VALID TO e <br /> (Applicant Name) STREET DRIVEWAYS: <br /> AREA QUAD 4/1,0,11( �V <br /> �v <br /> TYPE <br /> (Mailing Address) FORMS <br /> IV <br /> NOTES <br /> (City, State,Zip Code) <br /> —CA—rea Code-Telephone <br /> Sketch (Detailedplans 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 <br /> of feet/mile <br /> i , by performing the following work(description of work): <br /> LI <br /> C <br /> T- 4 <br /> Work 111*111 commence o—nor_abo_ut__T <br /> —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 /> I )P.-0 /1 A.-7 n� <br /> can cl'7 <br /> Sig atiu Appll�n -rT Title Date <br /> EVUB-SVINKIMASTEP PSIENCROACHMENT PERMIT APPUCATION.DOC (O1/DB) <br />