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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Jr2�Z, ��O�J OFFICE USE ONLY <br /> To: San Joaquin County JOB # 1/00.5_ REF # <br /> Department of Public Works APN CR # <br /> / •� EXP. DATE 05 <br /> lf/J�d1�1 ` �L2�1C Z b VALID 0" TO a DRIVEWAYS: <br /> App iicant Name) STREET AGNaun/ RY TI��E <br /> AREA QUAD �P <br /> TYPE r�1.1cyzAc k �t lir <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> o herwise encroach on Count Highway Right-of-Way on phe side of <br /> 4�r4 ix lace Qf Act <br /> performing the <br /> following work (d s ri tion o�fr wo}'k) <br /> Work will commence on or about y.�Q % _yg%Lt;z for approximately <br /> 2 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 /> izrjr�vl �-—�721?5nr zv� en;z <br /> 1 41 <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />