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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date // -1,76 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # IIX5- REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE =; a= <br /> VALID TDRIVEWAYS: <br /> Applicant Name) STREET * <br /> / � r AREA QUAD <br /> f TYPE <br /> e (Mailing ddress) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> other�w�i a encroach [�yn+Cyo�uyn�t/y Highway Right-of-Way on <br /> by performing the <br /> following work (description of work) : <br /> Work will commence on or about for approximately <br /> days. <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 /> i ec ' n approval. <br /> _i -z d� <br /> Si n trre-ofd <br /> Sign <br /> pplirant_._-__Tsle <br /> MASTER.PS\FEESCHDL (6/00) <br />