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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /v 3�_ 0 � OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR" # <br /> n P. DATE I! t <br /> Y� ��I1�5F-� Vf�L1d f'IS Lon gra ID �[ TO if 2 7-C7'? DRIVEWAYS: <br /> (Applicant Name) STREET * <br /> AREA D_-� -rPQUAD2 50 Jc <br /> TYPE <br /> (Mailin Adddrresss)952_V5— FORMS �- <br /> fD C_k, U I �- ! NOTE <br /> (City, State, Zip Code) <br /> 43 -- 6969 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) _ <br /> /c� Ki know 6 �s lkC All ��d c lvs�t f <br /> '�' . y - <br /> Lo-y , 2-4 err 4 ✓ �ct�'�s 2 �y93 �c�4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of by performing the <br /> follow i work (description of w rk) : <br /> A'DOU , <br /> Work will commence on or about 00 , for approximately <br /> 2� 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 /> in tion and pprova.l. <br /> Signature of Applicapk'- Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />