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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PR <br /> INT• <br /> Date ✓ . Z <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # (� <br /> Department of Public Works REF # <br /> APN CR" # <br /> EXP. DATE <br /> 61- 1-c�'j <br /> VALID -12 �`l TO <br /> (Applic nt Name) STREET3C ( —`— DRIVEWAYS: <br /> THo2fJ7aA1 . <br /> AREA F_I AG3 c,r! QUAD — <br /> � E'e TYPE ft'.1 pie <br /> "g <br /> (Mailing dress) FORMS 5-515-4l G <br /> icNOTE <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, construct and/or <br /> otherw'se en_croa h n C my Highway Right-of-Wayn othe �� ) <br /> side of <br /> pproximately, feet/mile 7 y <br /> following work (descri, i n of work) : n by erformin the ��77 <br /> Coo <br /> °h a <br /> Work will commence on or 46cut <br /> — days. for approxi ately f e ✓� <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 ature of Applicant - f� <br /> Date <br /> MASTER.PS\FEESCRDL (6/ <br />