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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN <br /> CR# <br /> EXP.DATE <br /> . VALIDTO DRIVEWAYS: <br /> (Applicant me) <br /> STREET <br /> AREA <br /> QUAD —I&VAI <br /> TYPE <br /> (mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> .50V VC1,)12,4� I <br /> 14?e-) � <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 High' <br /> the side of way Right-of-Way on <br /> of approximately feet/mile <br /> -no21 by performing the following work(description of work): <br /> Work will commence on or about r approximately <br /> 1,the undersigned,certify that I am the owner off 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 Titl <br /> t-!� <br /> Date <br /> MAGENTWSERIACEMLERICALIPUMV WO,4AsTEp <br /> 'Ps'ENcRoAcHA'Et4TPM,,TAPRjaA,nottDoc(o9m) <br />