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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date (O l r'`� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> rptEXP. DAT <br /> IX N�.(f k VALID (e 5 O� TO 7-1-07 DRIVEWAYS: <br /> (Applicant Name) STREET N ori/ ,elt <br /> 3 ti AREA s4Au7z5c-,-( QUAD <br /> TYPE -T.) <br /> (Mailing Address) FORMS <br /> 11116 NOTE <br /> (City, State„ Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may b submitted) 45 <br /> �4�u wiz <br /> Pzcw-z0n � ��w �?o'l �WY k3 ,1s <br /> �� �r►��trt�o <br /> S� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise gncroa h on County Highway Right-of-Waon the sideSof <br /> CA-V\ approximately t/mile S�ik, <br /> of /� c:cx y performing the <br /> followi g work (description of work) : <br /> Work will commence on or about for approximately <br /> 1WC-- 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 /> 11-ro <br /> Signa ure of Applicant - Title Date <br /> NiASTER.PS\FEESCHDL 16/00} <br />