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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �`� OFFICE USE ONLY <br /> To: San Joaquin County JOB # /�� REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT <br /> (T'�E C� A�l~- Co VALID Z5/0-7 TO DRIVEWAYS: <br /> (Applicant Name) STREET /11d11S 4z>-S-, <br /> pp1 AREA �SC�9GU�l� QUAD <br /> 1 b QX t�^ TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> Ot clS 2 0 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> z09 41 - 9s47 <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 11� side of <br /> 'J'o rt-t-4 t0roximately ��� ee /mile �+ " <br /> of t3NSF rtzAz*- µm111 C5Ct -1 by performing the <br /> following work (description of work) : Ujc5 Wtu-- LL-t' Avg N6-v c(ZaSs'rNL <br /> OA Sr 50�t-45 /qC C'N. W\f U� �5 CALvu c- UA\�- , l htiu�Z <br /> c-Nl� uy KITS c <br /> ( A•r I a.t ri <br /> Work will commence on or about 2 3 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 /> Signature of Applicant -Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br /> lz� r AW7 <br />