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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> P r LATE S DRIVEWAYS: <br /> .�ME6 r . j TO <br /> (Applicant Name) STREET <br /> AREA 5;rd-- �O QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 7 G r� <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 Highw Right-ofVUaY o <br /> the side of approximately feet/ ile N�✓'7 <br /> of O �' r h .T. c<�,TOAj by performing the following work(description of work): <br /> Work will commence on or about q d .30, y for approximately fv <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 /> I <br /> SignatIfire of Applicant-Title Date <br /> M.ICENTRALSERMCESCLERICALIPUB-SV.WKIMASTER-PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />