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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date rZ_`' 7 OFFICE USE ONLY <br /> TO: San Joaquin County JOB # s/ REF # <br /> Department of Public Works APN CR # <br /> _ EXP. DATE <br /> VALID f c TO DRIVEWAYS: <br /> (Applicant Name) STREET ;05� � <br /> AREA /y/ QUAD <br /> TYPE <br /> !G d/L�SeUA? <br /> (Ma ling Address) FORMS <br /> NOTE <br /> CA <br /> (City, State, Zip Code) <br /> 5, cc- _ G, J <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate cons and/or <br /> ° <br /> otherwise encroach on County Highway Right-of-Wa oa the �.�U� a- side of <br /> approximately feet/m le <br /> of 6 Qr� ��E t G 1�► by perf rm}ng the <br /> following work (description of work) -y Y IC r �i iCit� 17� On t-�Cl�'I <br /> Work ill 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 /> inspectionand,- approval. <br /> 1 <br /> 1.ri <br /> v 1 - <br /> Signature of Applicant - Title Date <br /> KASTER.PS\FS&SCOL (6/0 ) <br /> e-" {; .. <br />