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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # //D0!5�_ REF # <br /> Department of Public Works APN CR # fl3 l QS j <br /> EXP. DATE <br /> VALID /'D7 TO S/ 07 DRIVEWAYS: <br /> (Applicant Name) STREET -1kJV 0A1 AD. <br /> f AREA_PO4VToA,1 QUAD (/ <br /> TYPE <br /> (Mailing Address))) / FORMSAVW Z7 <br /> /4�1�,'Z) C/417-5 6 OzlNOTE <br /> �-T— <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r,nes�. <br /> C' <br /> X70f� r <br /> u $ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 64_5'r- side of <br /> approximately / feet <br /> offJf:�1� ff'� l�/� by performing the _ <br /> followin work (description of work) : cqc ' L _ -if <br /> Work will commence on or about ?/ / cU '� for approximately <br /> Q days. <br /> I, the undersigned cert=ify 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 A scant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />