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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 0-- 12j- 2 - <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />G1aF <br />(Area Code - Telephone Number) <br />(Email Address) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />Sketch (Detailed plans may be submitted) <br />C t_ <br />S <br />bot -1 Wit- <br />The undersigned hereby applies f9q{{ permission to excavate, construct and/or otherwise encroach on County Highway Rightof-Way on <br />the � side of Ibow w < o- j /! approximately 1'n6 ' feettmile c' <br />of o eck tic f Ln4+tY9 by performing the following work (description of work): <br />Work will commence on or after for approximately /FG 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 />Signarfudre of Applicant • Title Date <br />