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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> TO: San Joaquin County JOB '1 -4, <br /> Department of Public Works -------- REF# <br /> APN <br /> EXP.DATE CR <br /> VALID <br /> (Applicant Name) .0 0 10 J'r DRIVEWAYS: <br /> STREET <br /> earjh- AREA QUAD Z5� <br /> TYPE <br /> (Maili n�g <br /> Add�ress) FORMS le <br /> NOTES &,t eA <br /> (City,stll zip <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 <br /> the side of <br /> of approximately Highway Right-of-way on <br /> feet/mile <br /> by performing the following work(description of work): <br /> Work will commence on or about <br /> r approximate) <br /> y- days, <br /> f, 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 <br /> to inspection and approval. <br /> ------------------ 4-1 - <br /> S@nature of 11VIJI ELM It-Title <br /> bate <br /> WMaRA LSEP,14a=sicLsRi CAL,%B_SV ER PSe1CR0AC"R'VJT <br /> , PERf-'.ffAPPL1CAT1011'000 pjq <br />