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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# /�4J� REF# <br /> Department of Public Works APN CR# <br /> leEXP.DATECa `7 Vl�� � VALID 2 /L /3 TO 0 /s DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 1 AREA 1fmzkvb d QUA <br /> n 1{ e TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> Fr�o 15 3 <br /> (City, Statd,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 pe orming th following work(description of work): <br /> 6 � <br /> Work will commence on or about . zcyi 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 /> Q/1-7 <br /> Signature of Applicant-Title Nate <br /> E:IPUB-SV WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />