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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 2- -2 o A OFFICE USE ONLY <br /> To: San Joaquin County JOB # Agd- REF # <br /> Department of Public Works APN CR' # <br /> ��N A-N-T FO e j) U C"L 5 721lp IN EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET L/y <br /> I. l �� /i� /� Cy��1 AREA 46 4,*66 QUAD _ ,A/E <br /> �1 52 3 I-1"-Ll 7 C A TYPE WILUEA(/!A/ <br /> * <br /> (Mailing Address) FORMSf04tAy2 <br /> NOTE <br /> (City, State,. Zip Code) _, <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> rn ry <br /> v o <br /> <a „, <br /> O <br /> C <br /> Cn <br /> L� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 1=:7X-- side of <br /> C k prO e- -44AJg " approximately fl feet/mile <br /> of by performing tk�e <br /> following work (descriptionof wor ) /� t (- '/k <br /> Work will commence on or about for approximately <br /> J~ 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 /> ZZ <br /> Signature of Applicant - Title Date <br /> MASTER.PS\HEESCML (6/00) <br />