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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• I <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOS # REF # <br /> Department of Public works APN _ CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS. <br /> NOTE <br /> (City, State, -Zip Code) <br /> I <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan§ may be submitted) <br /> i <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on-Count Highway Right ox•the <br /> ' Y g Y 9 y�� :.,.• -. .: srids.•of:... . .. _ <br /> approximately feet/mile <br /> of by'performing the <br /> following work (description of work) : <br /> Work.will commence on or'about for approximately . <br /> days. <br /> I, the undersigned certify. that I am the owner' of.the respective property, or am <br /> qualified to represent..the owner and'_agree to, do .the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant Title Date <br /> MA8TSR.1?B\F=CML (6/00) <br />