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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date iJ OFFICE USE ONLY <br /> To: San Joaquin County JOB# X3005 2? 2d REF# <br /> Department of Public Works APN CR# <br /> EXP.DATEt�d - <br /> (Applicant <br /> DRIVEWAYS:VALID < O Name) STREET <br /> y AREA 15QUAD FS <br /> TYPE D _ <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> o9/p <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach y County Highway Right-of-Way on <br /> the `�� %%' side of .r`=/'- i /�'} approximately1/ rn/ feet/mile <br /> of ,by performing the following work(description of work): <br /> t t <br /> Work will commence on or about for approximately days. <br /> I,the undersigned, certify that,,am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in ordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Date <br /> Signature of Applicant-Title �i�%',G -T�' <br /> Y',FORMS d TEMPLUESIENCROACHMENT PERMIT APPLICATION.doc 1�1 <br />