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APPLICATION FOR ENCROACIENT PERMIT <br /> _PLEASEPRINT <br /> Date OFFICE USE ONLY <br /> I <br /> To: San Joaquin County JOB ## 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 /> i <br /> NOTE <br /> (City, state, zip Code) <br /> i <br /> (Area Code - Telephone Number) <br /> Sketch, (Detailed planh may be submitted) <br /> I <br /> I <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-TWay..ox-theI <br /> • ,.. ._ <br /> approximately feet/mile <br /> side.of <br /> of <br /> following work (description of,work) : r by performing the <br /> i <br /> Work will commence on or'about <br /> Sys for approximately <br /> I, the undersigned certify that I am the -owner' of;the respective propert <br /> qualified to represent. the owner y, or am <br /> 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 <br /> Date <br /> MASTHR•HS\F M OWL (6/00) <br /> � I <br /> I <br />