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APPLICATION FOR ENCROACHMENT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# eci j REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE r 2 ) -:c <br /> VALID TO — _2 -/•' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> - AREA — _QUAD SVS <br /> TYPE <br /> (Mailing Address) FORMS �(A)w =' J <br /> NOTES <br /> zJ-:r C- t✓ Com. 6�17 2 6-71 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> _C <br /> The undersigped hereby applies for permission to exavate, construct and/or otherwise encroach_ on County Highw Right-of-Way on <br /> the �i side of �C► C' approximately fee ile <br /> of by performi e following work escription of work): <br /> i <br /> Work will commence on or about l for approximately 1r days. <br /> t <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 ofApplicant-Title Date <br /> E:PUB&SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />