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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date �5 ��Z OFFICE USE ONLY <br /> To: San Joaquin County JOB # f( Oc,�;- REF # <br /> Department of Public Works APN 0 I6 -1 til-I q CR' # <br /> EXP. DATE .� f I i i) I <br /> IJ(�r. inn.VJC�crt/L �JG-- zz fru VALID TO T tv,% t i DRIVEWAYS: <br /> �S� (Applicant Name) STREET _A(:ApEx(� ✓� . <br /> 2 <br /> 4.// ELAREA Z(� r T QUAD ill t <br /> �23 sT TYPE US Li rl DLA I <br /> (Mailing Address) FORMS 56/ W A) <br /> f 2�U NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted)�ju , / <br /> U��-� /V <br /> � 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherw se encroach on County Highway Right-of-Wa on the fv side of <br /> �'GG E��, approximatelyee /mile ��-� <br /> of l.l!lJIG by performing the <br /> following work/+(description of work) 4_h e <br /> -7J,rn oa4 !!N r / 5r f.��,c. (. 4 xaJ��hoc SG 1 <br /> Work will commence on or aboutJlt 2�?>7 for approximately <br /> 3o 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 CZE' Date <br /> MASTER.PS\FEESC,IDL (6/00) <br />