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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# % REF# _ <br /> Department of Public Works APN CR# <br /> EXP. DATE j. ,z- Zg07 <br /> f`�, P\j VALID 3.• TO e _ DRIVEWAYS: <br /> ASh ° <br /> (Applicant Name) STREET <br /> j AREA QUAD <br /> 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 undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the � side of �_� a c�1 -f approximately 'tet 1 - ''dee mile <br /> of _ by performing the following work( escription of work): <br /> 1 <br /> L� <br /> Work will commence on or about for approximately <br /> 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 above in ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> XW �ENC- <br /> of Applicant TitleDate <br /> E IPUO- MENT PERMIT APPLICATION.DOC (01108) <br />