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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date At i C, IG 0 - OFFICE USE ONLY <br /> { <br /> To: San Joaquin County JOB # //DaS REF # <br /> Department of Public Works APN CR' # <br /> ^l EXP. DATE <br /> i m U- V 0 rVALID Q0-/07T0 q DRIVEWAYS: <br /> (Applicant Name) STREET _ LO4/G �dde <br /> AREA Zlha'en QUAD _ /LL E <br /> TYPE <br /> l (Mailing Address)2 FORMS S"Pe 4146keel <br /> N T CC�'t J NOTE v Lle� <br /> (City, State, Zip Code) <br /> 11 2) 0 6-o <br /> (Area Code - Telephone Number) <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 C"�� Ac -e- side of <br /> DV approximately mile <br /> of by performing the <br /> following work (description of work) : <br /> CJ <br /> Work will commence on or P r �T 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 /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspectiand,arVal. <br /> Signature of Appl:cant - Title Date <br /> MASTER.PS\FEESCHDL (6/00)' <br />