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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County <br />JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD * <br />TYPE * <br />(Mailing Address)FORMS <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 />Signature of Applicant - Title Date <br />E:\PUB-SV.WK\MASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />/PWFNCFS  <br />-JODPMO.VTJD#PPTUFST <br />10#PY <br />4UPDLUPO $" <br /> <br /> <br />4FFBUUBDIFENBQ <br />-JODPMO -FFTCVSH #FO)PMU )BSSJTCVSH <br />#BOE3FWJFX1BSBEF <br />Work will commence on or about _1RYHPEHU_ 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 />Digitally signed by Rachel <br />L. Grant Kiley <br />Date: 2022.11.01 <br />14:59:04 -07'00'11/1/22