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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4 -20 -o 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # //00 57 REF # <br /> Department of Public Works APN 0 - -3/ CR # <br /> EXP. DATE -x-07 <br /> VALID TO �/ DRIVEWAYS: <br /> (Applicant Name) STREET R2116,7 <br /> AREA _ h2dC,�= QUAD <br /> ,2 3 73 TYPE _Fru, +� <br /> (Mailing Address) FORMS Ss/ -��� Cw--b/ � Cw-M� -/7 <br /> NOTE <br /> 31pck4" 12A, 95 205 <br /> (City, State, Zip Code) <br /> - ( 20q) Y,/5 - 7G 5 - <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Sec AAoclnea <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oth rwise encroach on County Highway Right-of-Way on the _ �Sh side of <br /> on �uemu+c approximately _(IZ�U/mile 4LQry�6 <br /> of by performing the <br /> follow ng work (description of work) : p/.�+e /�� a r!�!� ate• <br /> 0440 <br /> Work will commence on or about 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 /> inspection and approval <br /> 7 <br /> �- Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (5/00) <br />