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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:. <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB 4 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /4- <br /> VALID t'F-TO ( 0 - /IF DRIVEWAYS: <br /> (Applicant Name)— STREET pW0i!9,- W 2 M((e Rd( <br /> AREA Del-fu QUAD /V W <br /> ..................... <br /> =T YPE�---- <br /> (k1lailingAddress) FORMS -2— <br /> rr NOTES <br /> (City,State,71p Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies or permission to excavate,construct andfor otherwise encroach on County High m Right-of-Way on <br /> the approximately feeUmile <br /> Of ----�f i <br /> by performing the following work(description of work): <br /> Work will commence on or about k1to N for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualif!6d to represent the owner and agree to do the <br /> work Cd ed above-n`7�cordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br />