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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /�2- 3 O —/ OFFICE USE ONLY <br /> To: 'San Joaquin County JOB# ( � (�(�(��j REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> /, ,yej 0 VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA Q AD _ <br /> /1 L) �/�:x? �g14q,1O TYPE Q h t t <br /> J (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 2� 6s s <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 /l/.3. side of approximately o fe mile <br /> of nia .� .�1�� �, � c�r .�-,-o" , by performing the following wort escription of work): <br /> Work will commence on or about for approximately 1--m 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 /> Signature of Applicant-Title Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br />