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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 5-1 co - OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR" # <br /> EXP. DATE Th2ZZa01 <br /> LVALID VJJZa.7 TO �S /f+o DRIVEWAYS: <br /> (Applicant Name) STREET Yonf d5/, L;.glen <br /> AREA L/ndrn QUAD 4!6 <br /> TYPE I_em1Aj1AC9 j 4awd C145vr- <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> �`>- _170 -2 357 <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 /> other ise encroach on County Highway Right-of-Way on the Nv,iLT1� side of <br /> '�Al- 5T', approximately feet/mile <br /> of , by performing the <br /> following work (description of work) : CZC�L�',rz" vF J= 0k.,7' S P'.� <br /> 41 5i 6'v 4MS r <br /> A)Ar',26-L. L/A1,0r_Tr C' J <br /> Work will commence on or about 14167 Z ZD 0 '7 for approximately <br /> r 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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCFDL (6/00) <br />