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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7 S OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> n' EXP. DAT <br /> VALID ? 6 TO 1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 2&C _ QUAD <br /> 510 1 TYPE / <br /> (Mailing Address) FORMSS Gym z <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1 <br /> I <br /> i <br /> 515 <br /> C -�o1v i <br /> The undersigned hereby applies for permission to excavate, constru and/or <br /> otherwise encroach on County Highway Right-of-Way on the S�Un4- \�14 side of <br /> approximately Pis- _j,30 eet ile W6S-r <br /> of --� 4L�'1L S <l'V , by performing tie <br /> following work (description of work) : 11-Z)C.K <br /> Work will commence on or about for approximately <br /> ,f We day . <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 /> Signa ure of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />