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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 1/005- REF # <br /> Department of Public Works APN I Z).9 - 070-OG CR' # OI3225 Z <br /> EXP. DATE 3 lot Yv Q <br /> _ AJC VALID �j 10:1 TO 5/110 K DRIVEWAYS: <br /> (Applicant Name) STREET .Zogp * , <br /> AREA STt�lcto 1.l 2UAD _ <br /> ZO I C. K �/G1E �IDG� r T yT 100 TYPE <br /> (Mailing Address) FORMS SLGJ K/ <<,9M <br /> Q NOTE <br /> (City, State, Zip Code) <br /> C9/e) �-7:7 -'&G <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 /> otherwise encroach on County Highway Right-of-Way on the side f <br /> Ne�-OtDr, ig"� approximately - tA0 feet/mom --.4 <br /> of 1r w,pr,}-a �/�/ r by performing the <br /> following work (description of work) : Fy- n 3-ani <br /> ��P L1�"t'Y�f\ �"`L� ��� l 3'l [�[7 l'1�Y i f"Z C-�.S]G__Gti L�-�\�r� �`•r/l rl L�� �SlS✓ <br /> rn � tP it t•�. � <br /> Work will commence on or about 7� {� - <br /> � for approximately <br /> . nw(441 <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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />