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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -��- OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> ® VALID I?09 TO -® ,v7 DRIVEWAYS: <br /> (Applicant Name) STREET CE/�21Sh'll4�✓ �• <br /> AREA TAG% QUAD Sw <br /> TYPE Fz!52-a GLEE <br /> (Mailing Address) FORMST <br /> � NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> I <br /> Lig <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on. County Highway Right-of-Way on-the �T, side of <br /> approximately (ao feet/mile b U-I"-)i <br /> of 0\11l% by performing the <br /> following work (description of work) : i m,itoU, 9 y, err <br /> Work will commence on. or about -1`1-9-? r: `" � for approximately <br /> -2- 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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCRDL (6/00) <br />