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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # llwG REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE /Z-/- 0 <br /> L ecd/l"rd o �{�tPT=y�� VALIDJ�� TO /Z-1-a7 DRIVEWAYS: <br /> (Applicant N:3me) STREET A /GO A <br /> AREA QUAD __ <br /> q S I °!c= /J� a�• �� TYPEr++� �� <br /> (Mailing Address) FORMS T Z9 <br /> NOTE <br /> r�i c <br /> C-4 , <br /> (City, State, Zip Code) <br /> C)J <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 41 17 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the N=r4 side of <br /> u,i 1 ,(0 approximately .��' fee mile <br /> of ��'�'�` hl� 11�''w by "performing the <br /> following work (description of work) : wv, Vit':- h 1 4- r,e <br /> Work will commence on or about -7 for approximately <br /> S 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 /> Signatu 'e of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />