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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / I��o OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE S/S U <br /> VALID T /S O DRIVEWAYS: <br /> (Applicant Name) STREET t�TAih/ aU <br /> Jh� / AREA _7z04_'y QUAD SCIS <br /> TYPE J�leG�f/✓� <br /> (Mailing Address) FORMS ST Lr.Y� <br /> t' T /-.j NOTE <br /> (Cityate Zi :Code) <br /> , FAX +IE--w <br /> (Area Code - Telephone Number) <br /> CGZ -7 ?b L lt(1V► <br /> Sketch (Detailed plans may be submitted) <br /> m <br /> �K • �df �� f��Ac'f1E� SF��,�L l'��.���r�s`�>�'�S•�b © � o�' <br /> 7.3 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way on-the _(Y1- side-of- <br /> I'��Ui1�z1W <br /> approximately C)00ee�/mile & Av '1�_ <br /> Of L0c",_d 0(E .e M _ZQS� by performing the <br /> following work (description of work) : <br /> Work will commence on or`about r 1 , A for approximately <br /> _ <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 /> lA6i�� <br /> Signat re of Applicant TAle -� Date <br /> MASTSR.MFEESCHM (6/00) - - <br />