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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date `b��— OFFICE USE ONLY <br /> OB # 1!065, REF # <br /> To: San Joaquin County JCR' # <br /> Department of Public Works APN <br /> EXP. DAT <br /> VALID S TO 7 O DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA A�9P QUAD M5 <br /> A- TYPE �fQY <br /> (Mailing Address) FORMS <br /> ;1,n NOTE <br /> (City, State, zipf`Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> rn q c!� <br /> r--.3 D <br /> -° C= 2 <br /> O �ip O <br /> f ^' SJ <br /> O y <br /> y� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of <br /> otherwise encroach on County Highway Right-of-Way on the <br /> side I <br /> �`r(►j P approximately feet/mile <br /> o f l,R 1 T( oi-, U i)uT&' qs , by performing the <br /> following wo t (desc 'ption of work) <br /> U(� <br /> Rbcurk Ze <br /> rt L <br /> fDQQS( <br /> ff% - for approximately <br /> Work will commence on or about <br /> b t�& 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 /> 4, ju <br /> Signature of Applicant - Title c>�_� s(�i Date <br /> MASTER.PS\FEESCHDL (6/00) <br />