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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2oQ OFFICE USE ONLY <br /> To: San Joaquin County JOB# ffQ(, 6 REF# <br /> Department of Public Works APN CR# <br /> (� EXP.DATE ©`f <br /> � �i -rf J��— ��/Cj� VALID • p•69 TO ��•/5•G9� DRIVEWAYS: <br /> (Applicant Name) STREET tbuS <br /> / AREA 5-MCk' QUAD <br /> TYPE i ?E'E1ot„E t <br /> (Mailing Address) FORMS -Z <br /> NOTES <br /> (City, State,Zi Code) <br /> (Area Code 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 Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description 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 tate <br /> YFORMS d TEM16TESVICROACHMENT PERMIT APPUCATION.Io,tOa'08) <br />