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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datef % OFFICE USE ONLY <br /> To: San Joaquin County JOB# _fs'��' REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE — — <br /> f ( VALID •��.j} TO .I. DRIVEWAYS: <br /> (Applic Name) STREET /dvA*r d6 za <br /> '? r AREA -57- <br /> d4krbAl QUAD <br /> V o, i1- TYPE Aoees <br /> (Maili g Address) FORMS <br /> ,{ NOTES <br /> `(City, State,Zip Code) <br /> (Area CodeTelephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> f � L <br /> i � • i <br /> The prod rsigned hereby applies for emissi n to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the side of approximately,IM fee ile <br /> of by performing the following work( ascription of work): <br /> � I <br /> r v <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 plicant-Title <br /> Date <br /> E.PUB-SV.WKIMASTER PS CROACHMENT PERMIT APPLICATION DOC (01/08) <br />