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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 l3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 6�f� REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 1b 13 <br /> VALID l l3 TO j /3 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 1,6Wj QUAD 41 <br /> TYPE 4eA- <br /> Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) e-,'11t5 <br /> ytlf',�215�. �'Zsy15, <br /> 7A <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 b / for approximately — 2 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 /> Signature of Applicant-Title Date <br /> Y TORMS&TEMPLATESTNCROACHMENT PERMIT APPLICATION.doc(08108) <br />