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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Cco I ► S OFFICE USE ONLY <br /> To: San Joaquin—County JOB# j i ✓cc REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID 27 TO y a _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> /( (-o) <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 feet/mile <br /> of _ by performing the following work (description of work): <br /> _ <br /> 1z''Q Gvg-c� <br /> Work will commence on or about_G 2 Z z�, for approximately �--�� � s Sys <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 /> Signat re.of Applicant•Titlec - <br /> Date <br /> W _.�INJAS TEF,.PSIEMROAC A'E NT PERM IT APPLICAT f014 OC (01!0"3) <br />