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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# <br /> REF# <br /> APN <br /> �j EXP. DATE CR <br /> 00 Z.p <br /> (Applicant Name) VALIDs TO <br /> '} STRE - - ' "f'° _ DRtvEWArS: <br /> f71 -f i AREA <br /> (Mailing Address) TYPE QN` <br /> i IFORMS <br /> C, C S� 2 NOTES <br /> (City, State,Zip Code) <br /> C 1� �'`f �i - <br /> (Area Code•Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> F <br /> The undersigned hereby applies for Perm' to e cavate <br /> the icJ side of ct and/or otherwise encroach on County <br /> if X Highway Right-of approximately "" � ght-of-Way on <br /> feet/mile <br /> by performing the following work(description of work): <br /> ork will commence on or about <br /> for approximately <br /> 1e undersigned, certify that I am the owner of the respective property, or <br /> rk described above in accordance with the rules and regulations of San � days <br /> am qualified to represent the owner and agree to do the <br /> Joaquin County and subject fo inspection and approval. <br /> Signature of Applicant- Title ,� o <br /> IaTEWPLA}Ea9r,CROACNWENT PERWTAPPUCATONdo iop/06} <br /> Date <br />