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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date L�lU - OFFICE USE ONLY <br /> TO: San Joaquin County JOB # AV 5 REF # <br /> Department of Public Works APN CR # <br /> � d'�.�� <br /> EXP. -DATE </z o <br /> VALID "e, & Td DRIVEWAYS <br /> (Applicant Name) STREET 6+^-C. <br /> //z �1 zLz(/. AREA. �-k� QUAD /V5 <br /> � �� TYPE 5�� � r * <br /> L (bailing Address))f FORMS. <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, const uct and/or <br /> of a ise encro ch on County Highway Right-of-Wa,Y--onthe �� side f - <br /> �°` approximately h' e /ale fl <br /> of by -perfo g the <br /> following work (description of,work) : -C 6ZId <br /> Work willcommence. on or'about 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 /> Signature of Appfr6aat Title Date <br /> MASTBR.PS\FESS®L (6/00) <br />