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w <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ,! <br /> Date V OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. _DAT /S <br /> VALID3 Qw DRIVEWAYS: <br /> (Applicant Name) STREETyi <br /> } j /'y����� AREA tV5rA�/ QUAD tl <br /> ���� (/1.6- ZA TYPE <br /> (Mailing Address) FORMS =-q—' GtJJfJ, <br /> NOTE <br /> (City, State, Zip Code) <br /> _. <br /> ' (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, Qonstruct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> -la <br /> 61 approximately l feet/A�e ��— <br /> of l by performing the <br /> fowl"ing wo k (description of work) <br /> adder — ZMtn 44 . ,,.. <br /> Work will commence on or about -G6 for approximately <br /> U5 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 /> tt��( JI D r <br /> Si ature of Applicant - Title <br /> r y��� T Date <br /> MAS'C .P \FEESCHGL (6/00) --"'- F 1O• <br /> • ME <br /> JM PROCESS1M DESK- BLD 1 <br /> 41040��Wj Lww <br /> STOC � <br /> T ON, � �. <br />