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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J OFFICE USE ONLY <br /> To: San Joaq in CoLy JOB# 7 3QDS'z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10-1,5-- 15 <br /> �i VALID TO DRIVEWAYS: <br /> (Applicant game STREET S cC1 13e /froa 2 0( <br /> AREA QUAD <br /> —r � <br /> TYPELP <br /> (Mailing Ad ress) FORMS � � 7 <br /> NOTES <br /> City,State,Zip Code) <br /> {Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The de ig ed hereby applies for permission tpp a avat c nstruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of u19�1 ,l, � approximately feet/mile <br /> of by performing the following work(description of work): <br /> r <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 /> Wna ofApplicarrt-Title f pDate <br />