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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date' is OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID /�S-d7 TO -/S-d8 DRIVEWAYS: <br /> (Applicant: Name) STREET <br /> r L, AREA STle-41 QUAD S <br /> 1/�1� ��frlly TYPE y�LE 7�.+PEtE'f� <br /> (Mailing Address) FORMS =55 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> T• �,oNTROL RLAN� <br /> SHLL BAER <br /> CURRENT�'M'U:TCD. <br /> G CAL F0 4 <br /> kEMENT <br /> i <br /> The undersigned hereby applies for permission .to.excavate, .construct and/or <br /> otherwise-encroach ori County.Highway Right-of-Wa:y"-Way-on the __ side.:of <br /> approximately ' '' feet/ rile �, ; "I <br /> of "l by -performirig the <br /> following <br /> FF work (description of. work) '"'r 4. <br /> Work will commence on or about 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 /> inspection and approval. <br /> Sin1?S\MSCFML <br /> ature of Applicant Title �z. ; v � Date <br /> MAS (6/00) <br />