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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date b OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11OOr REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT <br /> VALID 6Z TODRIVEWAYS: <br /> (Applicant Name) STREET Ap <br /> y AREA f,�,t,CW r24 UAD <br /> BUD `� � S't%DC7ZD) TYPE TI/¢Y��,GCD+VI'�oG Z�✓/GES* <br /> 1 (Mailing Address) FORMS - <br /> SG�. &-L ; (A q5qO) NOTE <br /> (City, State, Zip Code) <br /> -70-7 - 32& 1381 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> P/G ✓u-vri �y S/c'e�t/'ICG n2ne�v:• <br /> c � I <br /> The undersigned hereby applies for permission to excavate, onstruct and/or <br /> otherwise enc °ach on County Highway Right-of-Way on he 09T:r" side of <br /> V��• approximately _ ��0 �it�� feet/mile <br /> of by perfor ing the <br /> following work (description of work) 7'�4 41 <br /> work will commence on or about 45P MAP 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 /> inspectio and approval. <br /> v ,RfLgnature ofpApplic t <br /> t - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />