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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> RINT: <br /> Date / 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 1lW REF # <br /> Department of Public Works APN CR # <br /> - EXP. DAT /S <br /> VALID 0 ®7 DRIVEWAYS: <br /> (Applicant Name) STREET fIAI <br /> AREA 654q10AI QUAD <br /> TYPE <br /> (Mailing Address) FORMS0Q <br /> NOTE <br /> -A-`• � ,� ,� <br /> (City, S ate, Zip Code) <br /> rC � `-I_ <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> 101 rencro ch on County Highway Right-of-W} on the ' side of/ <br /> -,�� approximate) / feet/ it ��? ✓ f Gi <br /> of E. t'� it SCr� p r� by perform' g the <br /> fo�lowinr� work (description of work) : z' <br /> Work willcommence on or about4712,/ for approximately <br /> —7;1 <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 /> inspection and approval. <br /> �N <br /> gnatf Applicant - Title Date <br /> ure o <br /> i- <br /> MASTER.PS\FEESCIML (6/00) <br />