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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 16 30 1 1 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7 7. REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 1-4 <br /> vALID /1-r07 TO _44-62 DRIVEWAYS: <br /> (A licant Name) STREET <br /> n� p �j AREA . <br /> LAA,C�'y`� QUAD <br /> v�a l"l TYPE <br /> (Mailing A rase) FORMS <br /> C ',7 113 0 NOTE <br /> (dty, State, Zip Code) <br /> c (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r -T E / Int' <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 /> ofby 'performing the <br /> following work (description of work) : � :i S'?„J e r -G 'cam 1f k' �t� <br /> Work will commence on or about hAo rn�. ,���- % '�- � ” for approximately <br /> �r D <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 /> Signature of Applicant - Title Date <br /> ; <br /> MASTER,PS\FSHSCFIDL (6/001 / /p <br />