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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Mfr `. OFFICE USE ONLY <br /> To: San Joaquin County JOB# 'f3Aop2-c4 REF# — <br /> Department of Public Works APN CR# — <br /> / EXP. DATE //I6'�? DRIVEWAYS: <br /> f!% VALID TO <br /> (Applicant Name) STREET <br /> AREA w QUAD <br /> TYPE <br /> (Mailing Address) FORMS _ ! ,x0T.� —_ <br /> NOTES <br /> (City, State,Zip Code) <br /> r <br /> (Area Code•Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the /X <br /> �approximately l%1�c7 ` feet/mile <br /> of /��-"rte by performing the following work(description of work): <br /> Work will commence on or about ` 's!� for approximately ' �S" days. <br /> I,the undersigned,certify that I am the oer the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accorda cith e rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 7,1 <br /> nature of Applicant-Title Bate <br /> EIPUB SVWKMWER.PSIF_NCROACHMI NT PLRMITAPI`LICATION.DOC (01,08) <br />