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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date F <br /> 0 FICE USE ONLY <br /> To: San Joaquin County [JOB# jj � REF <br /> Department of Public Works PN CR# <br /> EXP.DATE <br /> VALID - .p TO DRIVEWAYS: <br /> (Applicant Name) STREET yv .AREA — <br /> O <br /> UAD <br /> TYPE T�'a ur <br /> (MaMing Address) FORMS r— <br /> 1 r ) NOTES <br /> 4 <br /> �.(nfe/f (City, State, Zip Co ) r' <br /> (Area Code-Te eepho a Number) <br /> 7Sketchled plans may be b d) <br /> PeZ <br /> i , �t <br /> TeRe <br /> e undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> •a -_� <br /> i C cin f4 <br /> Work will commence on or about for approximately days. <br /> I, 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 acne in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -% S' ature of Applicant-Title Date <br /> Y',FOPMS L TEMPLATES!ENCPOACHMENT PERMIT APPLICATIOM.d.c(We) <br />