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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date s OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /-130-/42 <br /> VALID //-/ -tSF TO 1.361- Co DRIVEWAYS: <br /> (Applicant Name) STREET <br /> } AREA A4ph QUAD <br /> • .� • i�: %' <� t TYPE fd <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> ( 4 7{ r l <br /> c ' <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 Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about 11-30/ for approximately C) 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:Wpg-S4.VNL'ASifR FS'E";CROACH'!E!Q PcRWTAPPlIG4Tp!JDOC(JLC•3j <br />