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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1�� 1� � L OFFICE USE ONLY <br /> f <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> (� <br /> EXP. DATE <br /> k,-CA vN LAND VALID 0 >t 0'" DRIVEWAYS <br /> (Applicant N ) STREET 4-5" <br /> AREA QUAD <br /> -I eA �ui TYPE <br /> ( iling Addre s) FORMS <br /> NOTE <br /> -2 <br /> (City, State, Zip Code) <br /> G 6 -- 0 '5 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �NC':.LLi7�ir i.�.1'';��� �`�L�j, f}rU%' L,.1C_�'_k= l+"� /;�njJ'}�f�`���C'=..1� [�{y✓/�'✓`'� ,�'6�5-�1r_'�,+.� <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroachn <br /> Ion County Highway Right-of-Way on-the We side of <br /> approximIT"tel -7oee G L /mile <br /> .N <br /> of ), ,� S inn;. S rv�-I �,� i by performing the <br /> following work (descri?tion of work) : IT <br /> Work will commence on or about 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 /> 2 -� <br /> S' =-Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />