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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date i D f 31 l u l OFFICE USE ONLY <br /> To: San Joaquin County JOB # -75077-3 REF # <br /> Department of Public Works APN CR # <br /> .T W�_�T EXP. DATE /Z-/-e <br /> VALID //�/�Ld TO IZ-1-6'7 DRIVEWAYS: <br /> (Applicant Name) STREET GUrtaZ�, <br /> AREA ��? �`lr9QUAD <br /> 23[r� 4 LLL��tl�l K 11 <br /> TYPE `�� /TSI <br /> (Mailing Address) FORMS <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-Way on the -- UbV'T-A side -of <br /> W iLA)t,-XDO V-0 approximately °(�2 feet/mile r--AST <br /> of S. cTPf—V_ -MMP-, fLD , by performing the <br /> following work (description of work) : DIL N` 1C Ll' X QI SPLILE PIT, PLALL C kD i, <br /> PEDLETXL E&LLCKU9_C. F-Oli IUF_W CQ D LC i1JAJPLgJnN1 <br /> Work will commence on or about MOV. lu , tUl for approximately <br /> IN 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 /> `� 2 <br /> gnature licant - Ti Ve JD to <br /> MASTER.PS\FEES L (6/00) <br />