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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # &06 S REF # <br /> Department of Public; works APN /)6.1^ CR # ©3Z.Ca(4, <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET_ CG Ae, <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> cc/`f z <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> I <br /> The undersigned hereby applies for permission to excavate, construc't and/or <br /> otherwise encroach on County Highway Right-of-Way on t e side of <br /> approximately <-c -� (e!e /mile e � <br /> of Lc-L-( I ZE'4"' 4 by performing the <br /> following work (description of Vork) : <br /> c k ,nG's<_�e':1� 2 �- lr_u.�i� � ,�� <br /> Work will commence on or about 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 rul-es, regulations of San Joaquin County and subject to <br /> inspection and approval.. <br /> 112 <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />