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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> aw 5 <br /> To: San Joaquin County JOB # 6 REF # <br /> Department of Public Works APN CR # <br /> �4/ EXP. DATE t-1S" ca <br /> J _ VALID12--Clti TO i-1 DRIVEWAYS: <br /> (Applicant Name) STREET �r. T +iFEE <br /> AREAGO <br /> TYPE QUA �-- <br /> ���' %��/vNt4� <br /> (Mailing Address) FORMS <br /> NOTE <br /> )( <br /> (City, State, !zip �Code) <br /> 'Ir0 Eq, <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �� � <br /> Li <br /> The undersigned hereby applies for permission to excavate, construct 'and/or <br /> otherwise enc ch on County Highway Right-of-Way on � ��€ <br /> approximately ee /mile <br /> of by performing the r <br /> foll�owi work (description of work) <br /> f� o �►�'G�.,(/� 1.► ARD Tp F2 om �7 l '-zP 5 I ►�I . 1 Cwt 5 rte�� <br /> -Pc(t- CK-">5 P-o '-ry oc,-7— Vfi-t- c-- 1>J" T v <br /> �,T ar\d -L>-7-7 <br /> Work will commence on or about for approximately <br /> 1!+ 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 /> Date <br /> Si ture f Applica <br /> nt Title MASTER.PS\FEESC�IDL (6/00) <br />