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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> �� <br /> jj _ EXP. DATE 9-4-0 <br /> 0-a r C-a.l � LP L '- VALID 9-4-6-7 TO 9-4-0'7 DRIVEWAYS: <br /> (Applicant Name) STREE cr '✓! G,4r.r ' <br /> AREA `!s'��GTI QUAD <br /> 05 Lf74-0'0 POIA --Ll,P TYPE - <br /> (Mailing Address) FORMS ✓r.�J `"�`�E <br /> NOTE <br /> (City, State, Zip Code) <br /> 6�TT�T� 71 �5 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> rn N <br /> cT,. <br /> Z7 :'.:? r <br /> -� © e�L <br /> A,1 A <br /> Cn <br /> �J <br /> Q <br /> v , <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the '4r,3'9side of <br /> Lv� LS IA, �dl approximately I•� feet/ it Lt S�' <br /> o f Tr <br /> by performing the <br /> following work (description/1 of work) • QA "'-,VG7 <br /> Work will commence on or about ���-( - O for approximately <br /> I 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 tionan approval. <br /> c��c tiM 3- ��_ 2 <br /> Si ature o pplicant: - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />