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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 2(?C) OFFICE USE ONLY <br /> To: San Joaquin County JOB # �'/04S` REF # <br /> Department of Public orks APN CR- <br /> EXP. <br /> R EXP. DATE <br /> 'til —;I-e 2 VALID TO DRIVEWAYS: <br /> (Applicant N e) STREET Z,9s'TF/1Ev✓ yK. <br /> � // �j® _ AREA 5?Yc,t/ QUAD <br /> r <br /> / 0 0_3 F `�i tL/ ! 7 � r Gf�✓I�G TYPE <br /> (Mai ing Address) FORMS 55 W�� <br /> n� (75-a/ NOTE <br /> (City, State, Zip Code) <br /> ao �3 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, conuct and/or <br /> otherwise encroach on County Highway Right-of-Way on the const side of <br /> As v t ec✓ y�;✓e approximately �� ee /mile <br /> of _C;4xi1el bV per-forming the <br /> following work (description of work) : Onr�O.,� (�f Wt� uJ ' e <br /> Work will commence on or about 2 :20 3 for approximately <br /> 10 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 /> 3q � <br /> Sig ure o pplican - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />