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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date v OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11z)05- REF # <br /> Department of Public Works APN CR # <br /> � <br /> EXP. DATE <br /> _ <br /> 1 •lC- VALID ;z-It --7 TO DRIVEWAYS: <br /> (Applicant Name STREET /.E'�'O�T a✓�" <br /> �n AREA -17A--1 QUAD L✓ <br /> TYPE `/z/l5 eGflAr-1 <br /> 'T <br /> (Mailing Address) FORMS <br /> L'-IL <br /> NOTE OTE <br /> (City, State,, Zip Code) <br /> ��GJ��� "- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> c� <br /> The undersigned hereby applies for permission to excavate, qqnstruct and/or <br /> of,4erwise encroach on County Highway Right-of-Way on the Li sid f <br /> f c`� apRroximately ' feet/mile <br /> of � L ��? r by performing the <br /> following work (de cription of work) : <br /> Work will commence on or about -// for approximately <br /> /C-) 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 /> MASTER.PS\FEES CHDL (6/00) <br />