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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date o_� I '�� OFFICE USE ONLY <br /> To: San Joaquin County JOB # AMC REF # <br /> Department of Public Works APN CR # <br /> c <br /> EXP. DATE '8-07 <br /> �-;v� �c�t �� VALID 6Cg5jg7 TO 4-8-67 DRIVEWAYS: s <br /> (Applicant e) STREET i,y1�, jD�d930 grn.,,'r'A1�� <br /> / AREA STc=k7V_A/ QUAD <br /> TYPE 0.liA, � Baer.¢ S/ren44 <br /> (Mailing Address) FORMS <br /> NOTE <br /> ari <br /> (City, State,. Zip Code) -- <br /> 20.7 _ 1y �- 0 `� 6 � ,lEo <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5et- 'lav <br /> The undersigned hereby applies for permission to exC vate, construe>D�J o7�EOT <br /> otherwise encroach on County Highway Right-of-Way ej&-the f� j it "noylS <br /> --1e -�-; Z feet/mile �. <br /> of by performing the <br /> following work (description of work) : r <br /> Work will commence on or about (n= 0 7 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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />