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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / OFFICE USE ONLY <br /> To: San Joaquin County JOB# r "a-itREF# <br /> D <br /> CR# <br /> Department of Public Works APN <br /> EXP.DATE DRIVEWAYS: <br /> /5// VALID <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> �i� ,i"-�'. <i/1c�✓�`'� ,,� TYPE � — <br /> (Mailing Address) FORMS ,G✓sv <br /> NOTES <br /> 14�Wz-Zjz /, " <br /> -- (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) �, c <br /> L./ <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> a roximatel J,' i�'� feet/mile <br /> the ZAy' t side of '� pp <br /> of y performing the following work(description of work): <br /> Work will commence on or about for approximately days. <br /> I,the undersigned, certify that I the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in a r ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant Title _,��p�, j'' Date <br /> Y'10RMS d TEMPLATESIENCPDACHMENT PEFMT APPLICAMN.Qoc 10&08) <br />