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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> j�%`t --'-- OFFICE USE ONLY <br /> To: San Joaquin County JOB # mon! REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 2'15-00 <br /> -v8 <br /> ��� �d�'U Li'�ir1.�"✓1ip? VALID 0-22_0 TO 0,15 DRIVEWAYS: <br /> (Applicant Name) STREET N � ' <br /> ,rte 1 AREA� ,41M QUAD <br /> J ->y ✓�<l ,' ��"1 12 D. TYPE ��UC.k I <br /> (Mailing Address) FORMS L04 RPIMY <br /> _ 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 /> otherwise encroach on County Highway Right-of-Wa� on the b� side of - <br /> � ' � , `!%, <br /> approximately „cif - fee /mile <br /> of 11_-V1y, 1:-& Ih'�L-I Lt��1 ['f by performing the <br /> following work (description of work) : "we'i'Y <br /> 01'_K. kA)` J_ 'TA K AF'POLS-r- 1FFfELy f',c T";' ( <br /> Work will commence on or aboutfor approximately <br /> sdays. <br /> �- <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 /> ANr <br /> Signature d Applicant - Title Date <br /> MASTER.PS\FRES=L (6/00) <br />