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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _� — — 07 OFFICE USE ONLY <br /> To: San Joaquin County JOB # �%% ' REF # <br /> Department of Public Works <br /> APN CR' # <br /> EXPV� ��ez 5 cc, VALID <br /> DATE <br /> VALID //-2-'-17 TO /f-Z?­� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA T L'r#4 QUAD 5�0 <br /> TYPE -T M, c-, , E C_ <br /> M ((Mailing Address) FORMS <br /> NOTE � <br /> (City, State, Zip Code) <br /> -�) 6 <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 /> therwise encroach on unty Highway Right-of-Way on the C,qSl. � �`[,ir�ide of - <br /> ( S LF" 1UR_Q approximately feet/mile <br /> of I , by performing the <br /> following work (description of work) : 0 F/V i I T - <br /> fl n-7 D' - i Q E 47 E 'U <br /> Work will commence on or about //—Z — 0-7 1�j 5--0 (for approximately <br /> 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 /> :ITC) tiESS EC_ S <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCEDL (6/00) <br />