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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date I O� OFFICE USE ONLY <br /> To: San Joaquin County JOB # 15?- (p REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE _ <br /> �i VALID *2�liiiil.Ll'lTO )5 Q(p DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREASg <br /> DI gQUAD �4646 1ASS-rPE _ <br /> x <br /> (Mailing Address) FORMS W T - <br /> n / NOTE- <br /> (City, <br /> OTE-(City, State, Zip Code) <br /> (Area Code - Telephone Number) c <br /> Sketch (Detailed plans may be submitted) <br /> c p 00 <br /> x07 <br /> W > <br /> The undersigned hereby applies for permission to excavate,�construct and/or <br /> otherwise encro ch on County Highway Right-of-Way on the 'p��+ side of <br /> approximate y feet/mks <br /> of r L by performing the <br /> followin work. (des ription of w rk) : <br /> Work will commence on or about — forpproxiinately <br /> 0�!�eadays . <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> nor (Aze, <br /> Si ature of Applicant - Title <br /> Date <br /> MAST .P FEE"C.L 46�.Oi RETURN Pa TO: <br /> • " V <br /> CA 04 <br />