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�,� � � i �y` ! "C <br /> APPLICATION FOR ENCROACHMENT PERMIT 2 ul J J G C,J <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin CountyJOB# 7 X00 REF# <br /> Department of Public Works JVC's APN CR# <br /> EXP.DATE IS <br /> --VALID 0 t TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS w hz ie <br /> NOTES <br /> NO � CA, 1-2-0 <br /> (City,State, Zip Code) <br /> 7? <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> t <br /> The undersigned ereby 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 <br /> by performing the following work(description of work): <br /> Work will commence on or about for approximately <br /> !----days. <br /> 1,the unqersigned,certify thalt I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work des ribed abo#in ac4rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> .ignlur of Appficant-Title Date <br /> M%CENFRALSERVICEWLERICAUPUB SVW0AASTCR PSIENCROACPMENT PERMIT APPOCATION.Doc 0(13) <br />