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a <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date g -/ i,-)C!D OFFICE USE ONLY <br /> To: San Joaquin County JOB # ZD REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> /'�apj� l/ 25�.4� VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET f�ifS S <br /> AREAfJV_��QUAD C <br /> TYPE <br /> (Mailing Address) FORMS <br /> � s NOTE <br /> /U Ili•" <br /> (City, Sta�e, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SrAl ��s <br /> �-i <br /> 0® <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of �'tTLI [�� �� gQI�< _, by performing the <br /> following work_ (didscription of work) : 0477-4 ig--p Z-9-OT" <br /> Work will commence on or about MZAIrh-6,r- AM nk IIYA-964t for approximately <br /> - 13 _ 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 /> S �0h4 11'grr{ 31(7 <br /> Signa ure of Applicant - Title 'T Z- 83J LQOl Date <br /> MASTER.PS\FEESCEDL (6/00) <br />