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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 07 - 0S - Z-007 OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��'� REF # <br /> Department of Public Works Apr? CR # <br /> ' �1 �1 /� EXP. DATE •/Sr'd7 <br /> ROLA �0 C7• L(�71ZP1�5� (AT-+-T- CrE}( l lelU�P�) VALID ✓ TO __7/S•�7 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA � QL AD <br /> 2300 TYPE (C �t{a <br /> (Mailing Address) FORMS <br /> �-1-0'cKTLK1 t Cr.A - t152,((j NOTE <br /> (City, State, Zip Code) <br /> 7-01 - '174- 46 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,- construct and/or <br /> otherwise encroach on County Highway -Right-of=Way on the E�1 �' side -of <br /> /k t2PN2 f approximately C�Z feet°mile <br /> of by performing the <br /> following work (description of work) : �p��E� <br /> G a <br /> ti <br /> Work will commence on or about <�l lly '(®07 <br /> , <br /> ( for approximately <br /> Z 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 /> 7Z3/6 7 <br /> Signature of Appli ant - Title Date <br /> MASTER.PS\FEBSCBDL (6/00) <br />