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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # #005- REF # <br /> Department of Public Works APN CR # <br /> EXP. DATES� 5'7 <br /> VALID � TO TO S I5-07 DRIVEWAYS: <br /> (Applicant Name) STREET '�I/�JyFt Q>, <br /> AREA LODi QUAD <br /> A ' <br /> TYPE J�/✓FY✓!4Y�UJL��tJ/AX STAB +4 <br /> (Mailing Address) FORMS 4&W, <br /> Lob i �A , q 5 NOTE <br /> �- <br /> (City, State, Zip Code) <br /> �, d q 3vRL5 - <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 /> otherwise encroach on County Highway Right-of-Way on the S6 J I H+ side of <br /> 7yRN C&jRn r) approximately '' � f:2�M tO4 4 h u <br /> of by performing the ►�` <br /> following work (description of, work) : to IN=dJ( r4 1 �`lf�c���� ftLCCSS <br /> r <br /> Work will commence on or about R I ` .Z80 for approximately <br /> o 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 app <br /> roval. <br /> c�,,i IYU 6- UftLe 4' c a ` <br /> Signature of Applicant - Title 1Dat6 <br /> MASTER.PS\FEESCHDL (6/00) <br />