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M <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 Q o OFFICE USE ONLY <br /> To: San Joaquin County JOB # DoS REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID 4-?-b TO -tS'-6 DRIVEWAYS: <br /> (Applicant Name) STREET APOU5 .fl,Q9E8iS <br /> AREA tU,9)fAZ;09 QUAD _ l <br /> Ssa a 0 TYPE 13O9!AXE _ <br /> (Mailing Address) FORMS S. <br /> NOTE <br /> 'R,09--- OAe— C k ��io�l t� <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> C sa• -,� <br /> Sketch (Detailed plans may be submitted) <br /> ra <br /> 00 <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 by perfgrming the <br /> following work (descripti n of work) : <br /> ex- 0-&k -A+°VLA 1? n 'P <br /> �4cec?�S , � 1�ttr�C1 5 Pre Y,cA- 12e,,-Lw-A, <br /> Work will commence on or aboutfor approximately <br /> Z rKch-,k,wv%&- 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 /> acco nce t the ules, regulations of San Joaquin County and subject to <br /> ins ec ion and p al <br /> — - mff� <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) '+ <br />