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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �T OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR" # <br /> EXP' DAT <br /> VALID f O DRIVEWAYS: <br /> (Applicant Name) STREET NiP-0NiGhE yL�. <br /> AREA QUAD AVIV <br /> --r <br /> _40'�6 td TYPE <br /> (Mailing Address) FORMS le-4 <br /> 6b � n Y 66., 9 NOTE <br /> (City, State, Zip Code) <br /> --- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> -t C7% <br /> Czrn <br /> �C? <br /> O <br /> ull <br /> o Ito 1 ,02 <br /> The undersigned hereby applies for permission to excavate, �construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the �4t)+ side of <br /> E= approximatel 14K5 ' <br /> feet/rt a _NC>r4+% <br /> of h/1 �' by performing the <br /> following work_ (d scription f w k) : <br /> 5 vrce PaAA,> �ce �� � ►c <br /> Work wi 1 commence on or about 5 •Ap for approximately <br /> 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 /> - Ibf 6A <br /> liaure of Applicant - Title Date <br /> FMMJM <br /> FEESCHDL (6/00) �'�'^C�'•• �. <br /> 4040'WOW Lm* <br />