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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date y/ OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE '/S- 07 <br /> v► / VALID 6;_ ig d TO 6-15167 DRIVEWAYS: <br /> (Applicant Name) STREET 4c5jCAAyr1,1U* kD. <br /> ((' AREA r)ee-11/ QUAD 5tJ <br /> ,3D6 �C/L.ci Ul is 1c-u TYPE rP_6Q-_K A eO P <br /> (Mailing Address) FORMS 5S W <br /> , teres � Cok-Z)ov,4 9�G70 NOTE <br /> (City, State, Zip Code) <br /> 2 0 7 9-5/9 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> ot,4erwise-encroach on County Highway Right-of-Way on-the/VD/ '-S'01477V side_of <br /> approximately <br /> aM 6^4 72t' OJ,,J,-77/ ��r�c� Zoo j2_&lCP .S_0.a Y - h "-per€orming the <br /> following work (description of work) : l /CK Up 00 C7- z4 <br /> _ CL!5e /,7, 77V ` <br /> D VLA �E 4 EAVO U,U /N /6 E C�of >�!1 2� l+- /"y <br /> 0 2 E AC/Zo . 7-,Vss T'c c"�. <br /> Work will commence on or about /�',D9S/ IF 20o "T 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 /> inspe ion and approval. <br /> Signature o Applicant- Title �f Date <br /> MASTER.PS\FEES®L (6/00) <br />