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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date —.,.& r' OFFICE USE ONLY <br /> To: San Joaquin County JOB# {((j�j� REF# <br /> Department <br /> of Public Works APN <br /> EXP.DATE CR# d <br /> -e 1 4 � . L {�� /S TO 20I�s►,,,` <br /> (Applicant Name) STREET <br /> •$ ��!— _ DRIVEWAYS: <br /> AREA <br /> C QUAD <br /> TYPE <br /> (Mailing Address) FORMS _qS ik% <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> I Sketch(Detailed plans may be submitted) <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 W�qS}� side of _ 1V� <br /> Of IA L6 4 approximately C feeVf <br /> �— by performing the following work(description of worm): <br /> Work will commence on or about_ <br /> for approximately <br /> days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and <br /> rk described above in accord nce with the rules and regulations of SJoaquin ins agree <br /> to do the <br /> '� ► ' , an County and subject to inspection and approval. <br /> o <br /> Sign ure of Applicant-Title <br /> Date <br /> E:PUB,SV.NlKIAfASTERPSIEN(;ROACHVENTPERUTAPPLICATION.DOC <br />