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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 9/5;12-00-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB #f�dD� REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT D S o7 <br /> lJaye CaY�'fye.� �, VALID 7 TO O d7 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA rL1255J�,9G6 QUAD <br /> 73 W. S e_vQcw--� Roc,d TYPE G"b,•E� XJ SI <br /> (Mailing Address) FORMS <br /> Lo- iyzp CA �I5330 NOT D <br /> (City, State, Zip Code) <br /> C2C i E2579 - 7900 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plains may be submitted) <br /> H <br /> Sem R-o�er SS ,aV-\8s' - Mossd��� 120 <br /> 1;�e.VY\ec�-,a-bio Y-� P1� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the Shut" side of <br /> E- approximately 31-7 2,--, feet/mile <br /> of m0_,_ �a ie _ by performing the <br /> following work (description of work) : Z" PC- (!)\)eu 1QA�1 wj P�tro�►lAt <br /> Work will commence on or about 10a 2C)67 for approximately <br /> l �} <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 /> t"4 ul—L,PM 1 aV !►t fr2 . _� `� j =�CSC j � <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />