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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / <br /> Date �52 <br /> �" E%�~ OFFICE USE ONLY <br /> To: San Joaquin County JOB# _Z3r 'a0 REF <br /> CR## <br /> Department of Public Works APN <br /> DRIVEWAYS: <br /> EXP.DATE <br /> �'� ��✓1�/ VALID TO !� 0.9 <br /> (Applicant Name) STREET 1A1- <br /> AREA QUAD <br /> iC1 / f_ ,/ TYPE <br /> (Mailing Address) FORMS <br /> f t'/1't `��✓! NOTES <br /> l/ Al <br /> (City, State,Zip Code) f <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P� ���D39fD <br /> Theunde signed hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the iV t e of �%t- �f , i'�' approximately -x feet/mile <br /> of by performing the following work(description of work): <br /> � _ <br /> � � <br /> Work will commence on or about / d for approximately days. <br /> IF <br /> I,the undersigned,certify that m the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in p6gr dance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title _ fs= T Date <br /> Y',FORMS 6 TEMPLATWENCROACHMENT PERMIT APPLICATION.dOc(0&08) <br />