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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ` �t ��ir _'. _ \�` 4 �UC OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE .✓��1'�- <br /> �� VALID //-/7-V? TO 11-17-.07 DRIVEWAYS: <br /> (Applicant Name) STREET �ii2✓�/� .� + <br /> AREA Al" QUAD <br /> TYPE -12'V „ ,oma e,'405el" <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 3 L� <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 /> otherwise encroach on County Highway Right-of-Way on-theside of - <br /> approximately feet/mile <br /> of _ , 1 by performing the <br /> foll wing wor (description of work) <br /> Work will comm nce on or about ��'Com` �� r ti��r1 C2cY'-) for approximately <br /> �s kC�r 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 /> LC 0 <br /> Sig ature f Applicant - +Title\ Date <br /> MASTER.PS\FEBSCRDL (6/00) �. �'� 1C�.:>� i� 1 ^�"'�._a��,. ?'^ s,��`.-A'C0�...-,y <br />