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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f ��t OFFICE USE ONLY <br /> To: San Joaquin County JOB# �� �' REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE 20"o <br /> I —tyY VALID d/40 TO DRIVEWAYS: <br /> (Applicant Name) STREET �u <br /> AREA ZKL7-- QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> I� <br /> f <br /> I <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 /> l--f>G.��t tC��.i S (.•�.�->CG-�"��C� Gtr---S ��-L-i2.1��S�, - <br /> Work will commence on or about_�-f �e,- o for approximately 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 /> Signature dfAoplicant-Title Z, Datef <br /> EI LJB-SV.WKIMASTERPSIENCROACHMENTPERMTAPPLICATION.GCC (DIM) <br />