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APPLICATION FOR ENCROACHMENT c { <br /> PLEASE PRINT: w o SS <br /> Date ✓ 1� U�IFti <br /> To: San Joaquin County JOB # -?-1057z-( REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE d / W <br /> VALID '¢ OCD TO / OCD DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA 5rleo/ ,, QUAD <br /> TYPE X" A" f* -r~6# * <br /> (Mailing Address) FORMS AA&Z .�L9 <br /> NOTE` <br /> (City, State, Zip Code) <br /> ,IAZ - IC��L� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 10« a-75 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> other ise encroach on County Highway Right-of-Way on th))e o zi4b side of <br /> approximate) l(�1 feet/ <br /> of by performing Athhhe <br /> following ork (description of work) : <br /> Work will commence on or about -C� for approximately <br /> 6 2V 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 /> inspection and approval. <br /> '4WN - t4 6i 6� lffth <br /> Si ature RETURN PEFi1MRS TO:of Applicant - Title Date <br /> P9AST .P \FEESCHDL (6/00) Pam <br /> �bB PROCESSING DESK- BLD 1 <br />