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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date _��.; <br /> / FAPN <br /> FFICE USE ONLY <br /> To: San Joaquin County yj�Department of Pulic WorksREF ##CR• # <br /> I(- tS'-D'�l�c'T�"�e r��. l-o7 TO I(-rse�'(App icant Name) DRIVEWAYS: <br /> �Q/dt'S LOCAT)QUADNE5 <br /> (Mailing Address) FORMS S5 NILii, /L Z�f <br /> U <br /> ca � NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> sue ,x(19 cl(2 ;I&,�s re i r� c It,[ ded-ct 1r .�y , : � : W� 4cw <br /> 5 ��+�LS x iF SAN�OR%'UI,V GpU,vey �2EQuE5T !�v T/fE �clTtlo2E �-oi2 elr&rngs To $6, Loc <br /> ® L'rTY a�'La�j�=LECfQrG P�/tiTy S',rrALc DO So �%VD Cb5`T"?b Si9N,ToAGJU/il! �JdRJt?� <br /> ak 7>/�1ANcF CRan? EDGE df P//dF.�� ,Sr�Att Ae <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the <br /> of approximately feet mile side of <br /> folvowing work (descr:ipt'.on of work) : 1 1 �� �, by performing the <br /> < . <br /> �`n A/ �w' - `C'/✓ <br /> 10 <br /> Work will commence on or about <br /> 3 1 Ci -V LaCC'i' / .loci <br /> C' days. for approximately <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 �L7 •.� f � � <br /> Date <br /> MA.STER.PS\FEESCHDL (6/00) <br />