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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> — ����t�� �:.Z D d 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB# //p REF# <br /> Department of Public Works f APN CR# <br /> VALID�^r,� 0�' �,t�t/P_/'�'V�t EXP.DATE <br /> �. a TO _f 07 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAte- QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> 4NOTES <br /> (City,,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Sae_ !� A XL.r br�t- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about_ for approximately 97,p– 3 n <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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 4 <br /> Signature of Applicant-Title ���� <br /> Date <br /> E WUR SV Wk1MASTER PS4E NCROACNMENT PERMIT APPLICATION DOC (01g8) <br />