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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S- OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> f <br /> EXP. DATE 11-1-<-.0'7 <br /> (2O VALID fid'/ '07 TO //-/S-d7 DRIVEWAYS <br /> (Applicant Name) STREET 44tlJ� •� <br /> �Q CS O4,6--) AREA QUAD <br /> TYPE 7X6W-&1" <br /> (Mailing Address) FORMS <br /> g? o8 NOTE <br /> (City, State, Zip Code) <br /> Zd9-- 9`13•� a ( -- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) ti 90/s <br /> tie -fdN �� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise en2croach on County Highway Right-of-Way-on the -F sid . f <br /> NQWiia e <br /> k'-ft J approximately 2 S <br /> a t/mile ale <br /> of 1 �'' byperforming the <br /> following work (des ription of work) : 5�.� -S"} �L�_ 1`I Oa ' 12 1 W ni-22 ma)ti <br /> Work will commence on or about O`? for approximately <br /> 7-4�1$ 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 /> MASTBR.PS\FBBSCYML (6/00) <br />