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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /fir f j OFFICE USE ONLY <br /> To: San Joaquin County JOB# /f REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 4 )3 TO 13 DRIVEWAYS: <br /> (Applicant Name) STREET 1by�l <br /> AREA 0 QUAD <br /> TYPE <br /> (Mailing Address) FORMS V16,Z1 tN. QpUC, <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> /✓1i✓1 n T t� ,�O� �5 /��. <br /> </-.70 <br /> P <br /> , ,no(/� r�lv�✓rr�� , DLLs <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the �U'� � side of 7 approximately z$: 3)r, feet/:le <br /> of f &14e'4 <br /> , by performing t e following work(description of work): <br /> 1 <br /> Work will commence on or about ,��,r/ �� � for approximately 7 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 de/scribed abo a in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> YAFORt 9&TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc(08/08) <br />