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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB 4 <br /> Department ofPublic works APN REF # <br /> EXP. DATECR # <br /> (Applicant Name) VALID TO •/5-STREET GY <br /> DRIVEWAYS: <br /> AREA <br /> (Mailing Address) TYPE <br /> FORMS <br /> NOTE <br /> (City, State, Zip Code)- <br /> _N_ <br /> ---------------------------------- <br /> ---------------- <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned herebyapplies for permission to excavate, construct and/or <br /> Ot herTfise encroac,� on County Highway Right-of-Way on the 1�tl <br /> '7' <br /> of I <br /> approximately side of <br /> / --)-� feet/mile <br /> following work' (descr <br /> iption of work) - by performing the <br /> e" <br /> Ld <br /> or, '.7 <br /> C_ 4 <br /> 7 <br /> work will commence n or about <br /> !L <br /> days, <br /> for approximately <br /> the undersigned certify that I 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 <br /> inspection and approval . County and subject to <br /> signature of Applicant <br /> MASTER.FS'FERSCJ_-L (6,'C 0 Date <br />