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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -J OFFICE USE ONLY <br /> To: San Joaquin County JOB # M2 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 4- 3o-o ) <br /> G0 VALID 4-Z`i--0-7 TO #-30-617 DRIVEWAYS: <br /> (Applicant N (e) STREET A.L--,-7rZ).) P-2>- <br /> AREAS CTO QUAD A160 <br /> ��U TYPE <br /> (Mailing Address) FORMS <br /> _ NOTE <br /> 1211,- L< Gam, 944 <br /> (City, State, Zip Code)) <br /> -0 72— 4 /// <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) See aHaC,tepe <br /> P 010sU4e.,9h v 7- <br /> &Z _ y - - ?0-7 lQoi <br /> Oel'7 gyp, 2607 6�G'�l <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the nt alide of <br /> i(/fcc w led, approximately i z� fee /mile Spin, <br /> of �-' ��� 4Wi fCovi �/tsc, by performing the <br /> follow4 <br /> 1 work)J (description of work) <br /> Work will commence on or about 700 for approximately <br /> 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 /> inspecti rova.l. <br /> Si f Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />