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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> / o <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# (j Q !/ S REF# <br /> Department of Public Works APN CR# <br /> AM <br /> nEXP.DATE g-( — /f1 (J VALID 6'Z3�-15 TO -1 S DRIVEWAYS: <br /> (Applicant Name) STREET 1u-f4b, (an 2 <br /> AEA/'� 60K a / O TYPE gore QUAD <br /> .�7 (Mailing Address) FORMS <br /> �! v <br /> �lo� &t. /j_5 401 NOTES <br /> (City, tate,Zip Code) (/� <br /> - <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permissio to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Uth syf r a G- approximately feet/mile <br /> of i io!a11_� , by performing the following work(description of work): <br /> Work will commence on or about for approximately 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.IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOG (01108) <br />