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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 1 � OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> �QQ EXP. DATE <br /> u L � VALID TO -D DRIVEWAYS: <br /> (App icant Name) STREET CLA Amll 10l <br /> ` O7P)Q�— AREAuG/!ib QUAD Z I./ _ <br /> TYPE �,0✓Wa14 <br /> (Mailing Address) FORMS -G Z <br /> NOTE <br /> (City, State, Zip Code) <br /> 13, �'-7 90 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate onstruct and/or <br /> otherwise enc oa h on ty Highway Right-of-Wa on the WE5l _ side of <br /> Co (� pr imately15_ _ eeb/mile <br /> of � by performing t e <br /> follow ng work de cription qf w rk) : <br /> 7W 0 <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 /> acc rda wwith the rules, regulati s of San Joaquin County and subject to <br /> spection ar .approval. <br /> f�o <br /> Signature of Appl ' a t J- tl � � �, ate <br /> MASTER.PS\FEESCHDL (6/0t� �� 1 JJ� \ =��L.• <br /> r <br /> _"707 <br />