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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # d422:�� REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE ^Z4-67 <br /> r—\ V`C'- �-�� VALID -Z3-qTO -e7 DRIVEWAYS: <br /> (Applicant Name) STREET0-0-AL. vLL Y� �• <br /> r AREA 'lQUAD <br /> S Z o \ X-o., c y �3��� • TYPE J--)MU2 �A+T2~E W S►L�rI — <br /> (Mailing Address) FORMS �- <br /> \ G NOTE <br /> (City, State, Zip Code) <br /> L -, '1 - S-L 1 - �� 4- 0 2- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> fie_.. tient 'F" ... '�- lti'it" .�. : <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Co ty Highway Right-of-Way on the side of <br /> coy r °` fin 11o,w R t approximatelyfee mile <br /> of Y1Y`A b perforin the <br /> following work (description of work) : �/��� �� �'QS 3'C C Y'O jS\r,� <br /> an 1 q h n 1 3 cl EV1 CL. �f 1 ec9 <br /> an ` dui o i R. CY o S'�"� r�b <br /> Workw' ll commence on or about r''1 6677 for approximately <br /> days. l <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 App ant - Title ; _ Date <br /> MASTER.PS\FEESCHDL (6/00) <br />