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PLEASE PRINT: <br />Date <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />Code -Telephone Number) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) � � � U�� �k <br />cp <br />AL <br />t <br />13 W <br />CA tA <br />OFFICE USE ONLY <br />JOB# IIQDo 5 REF# PS` <br />APN CR # <br />EXP, DATE ' q; / j / q <br />VALID o t TO q /1 /1 <br />STREET olkzvytCeC Roa4 <br />AREA $4o614 ho in QUAD Aj U) <br />TYPE 'n Nei L u S$�sa� �x D►^t9c� <br />FORMS <br />NOTES r <br />I�p3gQ� <br />DRIVEWAYS: <br />►:ae <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 feeflmile <br />of by performing the following work (description of work). <br />Work will commence on or after <br />I, the undersi ed, certify that I am the owner of the respective property, or am qualified io represent Rate the owner and agree to do the <br />work�crit��above in accord��� with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Yee ))e <br />Signature o� Applicant - Tifle <br />A 7E1,1P1A7E51ENCROACHIAENf PENAIT APPLICATION.doO (OBf08) <br />