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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -7 /-3 v 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # � REF # <br /> Department of Public Works APN CR" # <br /> 1 <br /> EXP. DATE <br /> (ti/�STfi(7� t ��?T.xPZ (_/c'i✓�!�?�e�iizS VALID -00-07 TO �O-/s d7 DRIVEWAYS: <br /> (Applicant Name) STREET 7P�4,a 4D- * <br /> AREA/"4,-/,-,/ QUAD /✓� <br /> 7G ? /Q v i y ¢ /vim�' TYPE ?2W,45-�e- fdAJT39G <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 7ej.7 <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 side of <br /> /'14 ACS 7'�-„ approximately feet/nIM <br /> of 0, J?,-( 1 —1by performing the <br /> following work (description of work) : Rem/ _P.-- ,' x, <br /> Work will commence on or about �c:�� ��baa 2c� for approximately <br /> 2 <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 /> Sifn a re of AppZ cant. - Title Date <br /> MASTER.PS\FEES CHDL (6/00) <br />