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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Ll-- -� -C"/�. <br /> . OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> Kle;'i C'e i'ier <br /> EXP. DATE <br /> ------ VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area 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 '10� approximately_ -D <br /> 'w' Dee mile <br /> of �0 <br /> by performing the following work (description of work): <br /> Work will commence on or about_ =_r' -0 1 <br /> for approximately days. <br /> 1, 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 /> F 1P!JB SVWKIMAS IFR FISILNCROACIIMI,N I PC RMIi APPI ICA I ION DOC (01108) <br />