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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date A 1-1 2 00 OFFICE USE ONLY <br /> To: San Joaquin County JOB #� REF # <br /> Department of Public Works APN CR # <br /> / �/+/''t) EXP. DATE S-/$=p'7 <br /> i / ✓y'/?/ Li /�i y Z� VALID �E- -O7 TO 5%/5-07 DRIVEWAYS: <br /> (Applicant Name) STREET FL A9441 j �� <br /> AREA ts1'cC QUAD 1ys <br /> ® <br /> 6 '� 4 -S7 TYPE r2E5 <br /> (Mailing Address) FORMS SSAA41 ,Q-2 <br /> ' NOTE <br /> (City, S ate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans m�ayy`- be submitted) <br /> ' <br /> A?�F's1V1G� 5aXle,X lovi �� 6� �1'® L�1�4P�I f�rau5 4 Gose <br /> f�/` Cc vt P s' /�1�A c L a h 1`"h L� �lci/L W Y K y el a 0 a 11pt_J, � 14, <br /> W, f' vost` <br /> The undersigned hereby applies for permission to excavate, constr ct and/or <br /> otherwise encroach on County Highway Right-of-Way on the N "f 2 S° side of <br /> _ —51 /�L�i�f�� _S/ approximately <br /> of b performing the <br /> following work (description of work) : <br /> h . <br /> Ve <br /> Work will commence on or about Go for approximately <br /> /d 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 D e <br /> MASTER.PS\FEESCHDL (6/00) <br />