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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT; <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 �34Zw REF# <br /> Department of Public Works APN <br /> AD <br /> ® CR# <br /> EXP. DATE ,�e r �,� <br /> VALID <br /> (Applicant Name) -- STREET /a ! DRIVEWAYS: <br /> 410 _—_—__ TRE U ,t <br /> (Mailing Address) FORMS <br /> NOTES <br /> � <br /> (City, State, Zip(;ode) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi.ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of—1� <br /> of i Zapproximately e mile <br /> — — d&��A by performing the following work(description of work): <br /> Work will commence on or about ,® � <br /> �- for approximately d.�� 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 /> —4Signature of Applicant-Title �� l <br /> Date <br /> M.ICENTRALSERVICESICLERICALIPU6-SVWKUJ,ASTER.PSIENCROACNMENTPERP.IITAPPLICATION.000 (09113) <br />