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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> 7AREA <br /> FFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works REF ## <br /> CR. # <br /> O-!S= 0Applic ntName) TO /b-/ 7 DRIVEfaTAY3: <br /> rl'9 J`iKdpG/ QUAD S� <br /> (Mailing Address) TYPE i/I/s7-you G,pTrilc�,4c//1� <br /> ��— FORMS ---- <br /> �I�Io/,/ NOTE <br /> (City, State, Zip Code) <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 /> other w'se- encroach on County- Highway Right-of-w. <br /> y�YW t� qn theF/�S'T-side of <br /> of s'r� �7�",e /% approximately _ >�'� pD e e <br /> -- <br /> following work (d �?XyIJ. <br /> escri tion of work) : by performing the <br /> r � <br /> e <br /> Work will commence on or about <br /> � a <br /> days. for approximately <br /> I� thundersigned certify that I am the owner of the respective property, or am <br /> alifi d to represent the owner and agree to do the work described above in <br /> accord nce with the rules, regulations of San <br /> ins `ction and ap roval. Joaquin County and subject to <br /> p� <br /> Signature o p licant - Tit <br /> Date <br /> MASTER.PS\FSESCFIDL (6/00) - <br />