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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 44z921—------------ OFFICE <br /> USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works FA <br /> UU S REF # <br /> CR' # <br /> (Applicant Name) TODRIVEWAYS: <br /> �1 �7�./ �j <'' T �/7,1 QUAD _ '5& <br /> 1 3 `�''T TYPE <br /> (Mailing Address) i � „'���•' ' - <br /> 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, con t_ r ct and or <br /> otherwise encroach on County Highway Right-of-Wa <br /> M �� it the - sl e of <br /> of - approximately f et/mile 4 t <br /> – Sc tc-+u <br /> following work (descript:ion of work) : <br /> - by perforrping the <br /> u ”' ,, c' <br /> (c CAL - k <br /> Work will commence on or about <br /> days. for approximately <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 an approval. <br /> Signature of ppl3 t - Title o4Zov <br /> Date <br /> MASTER.PS\FEESCFIDL (6/00} <br />