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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date A P�a-c/�- /Z ?_0® � OFFICE USE ONLY <br /> To: San Joaquin County JOB # I/yUS- REF # <br /> Department of Public Works APN CR" # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREETA/�ertyAl J J.4-rgQdP_-'D_I V ' (\N �-/� - �0 6- c- 't6 AREA F)1.7�E CK� QUAD <br /> TYPE 77vTtX�� .���Jy4r , <br /> (Mailing Address) FORMS <br /> 5c) NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> tc', <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of , by performing the <br /> following work (description of work) : <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 /> i nature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (5/00) <br />