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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> A. <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works APN CR# <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET zwuI16 <br /> AREA G.-M ek QUAD <br /> TYPE <br /> NOTES <br /> (City,Stiti,Zip Code) <br /> W\reaCmda-Telephone Number) <br /> Sketch(Detailed plans may beSUbmitted) <br /> The u derpigned hereby applieAfor permission to excavate,construct and/or otherwise encroach on qunty.H�h av Riaht-of-Way?n <br /> approximately il <br /> of <br /> by performing the following work(desc ion of work): <br /> Work will commence on or about for approximately --7 days. <br /> [the undersigned,certify that| arri 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 /> sigin9turp,of Applicant-Title -J Date <br /> E PUS SVWK%MASTF§rkNCR;&&.;PT'�'iT APPLICATION DOG (01108) <br />