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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date // - /�� /�~ OFFICE USE ONLY <br /> To� San Joaquin County <br /> Department of Public Works <br /> �7} . �` <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET C <br /> TYPE <br /> AREA QUADNI(Mailing Address) FORMS <br /> NOTES <br /> 7 <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersignedh bapplies for permission exc vate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of "4exc approximately_35-, i10 feet/n�* <br /> of r)5,_(2 fl,�J by performing'the following work(description of work): <br /> Work will commence on or about for approximately i) days. <br /> 1,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 /> ' <br /> Signature ovApplicant'Title Date <br /> '=;S= =ENC�OACHMF°'*=IIT~�!CAT'ON DOC (01M) <br />