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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# *Jip' 0?6?K REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 4W. •tS <br /> VALID 41iP _ TO 9 DRIVEWAYS: <br /> (Applicant Name) STREET oA/TGiNE A <br /> AREA -74, 4e y QUAD _ <br /> ZC I Srr iCc {t! t -tet r � 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 Highwa Right-of on <br /> the side of •� Ae a 1 y <br /> AW- d , r E q � t Sy performing the following work(description of work): <br /> Work will commence on or about 17 jt:r Iti-buL Z+oei for approximately I 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-ab Fn.ac rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> et <br /> Signature of Applicant-Title Date <br /> YtFORMS 8 TEMPIATESENCROACHMENT PERMIT APPLICATION da(080) <br />