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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date �- YOFFICE USE ONLY <br /> To: San Joaquin County JOB # //OOS REF # <br /> Department of Public works , l APN CR # <br /> 53 Cop v�d �f- IA C06 �U��Vvl1� <br /> EXP. DATE <br /> aov ALID TO DRIVEWAXS: <br /> (Applicant Name) STREET �� S " 374"e-f <br /> I (� AREA S4oc/c% QUAD SS <br /> TYPE <br /> (Mailing Address) FORMS <br /> L � C/7 s �06 NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ( <br /> a 71 <br /> M 7e <br /> S �. s <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> other w' se encroach on County Highway Right-of-Way on the side of <br /> IL approximately fee /mile 5d4I7--41 <br /> of A £T, G by performing the <br /> foll wing wor (descr'ption of work) : e C�21/ <br /> 6 e 1 t - <br /> t,+ I o <br /> Work will commence on or about for approximately <br /> oy(i 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 a roval,--�) <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESC= (6/00) <br />