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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE <br /> J�PRINT <br /> OFFICE USE ONLY <br /> To; San Joaquin county REF # <br /> Department of Public Works Aper <br /> CR # <br /> EXP, <br /> AT r O <br /> L VALID z b T o <br /> (Applicant Name) DRIVEWAYS: <br /> STREET <br /> AREA OUA <br /> TYPE .D <br /> (mailing Addresq) <br /> FORMS � <br /> (Citi, State, Zip Code) NoTE <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, o struct and/or <br /> ache kL,-> encroach an County Highway Right-of-way on the S 6 ( side of <br /> �-�i G N Wa4 y •7 � <br /> of -----_ approximately �C�tii�ltr� feet/mile. <br /> llowing work (deecrip.tion f work) : CL by per Srming the <br /> -�- l_ �F_c��C� <br /> 1 D C <br /> work will commence on or about vQ <br /> d&tlt- daysfor approximately <br /> 1, the undersigned certify that 1 am the owner of the respective property, or am <br /> qualified to represent the owner 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 proval. <br /> 4B,5na <br /> ra of Applicant - T4tle <br /> Date <br /> M118T2tt.GC1NUIi;ictmn to/0 J] <br />