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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# // S' REF# <br /> Department of Public Works APN CR# <br /> EXP" DATE .¢ <br /> i a Oji � �i �� VALID � 25" a T TO � o Z DRIVEWAYS: <br /> l <br /> * <br /> (Applicant Name) STREET <br /> AREA 1-2%4e so QUAD 51,E <br /> TYPE 'cTfi+A�ES <br /> qPrailing Address) FORMS �Ag , - <br /> 2>?�t�i'' /� /� -� NOTES . <br /> (City,State,Zip Code) <br /> (Area Code-Telephon!�,N umber <br /> Sketch(Detailed plans may be submitted) <br /> i <br /> The undersigned hereby applies for permission tate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_254 f side of '' / � approximately/at- feettmile. . <br /> of 446r ,4 L,:: ,by performing the following work(de ' ion of work): <br /> Work will commence on or about for approximately 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 /> Signature of Applicant-Title Date <br /> YTORMS&TEMPLATESAENCROACHMENT PEFUT APPUCADON.x N 081 <br />