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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ®-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB ## %/ REF # <br /> Department of Public Works APN - CR' # <br /> < <br /> EXP. DAT <br /> '*o/ <br /> 'c./1 VALID / 4n 0 DRIVEWAYS <br /> (Applicant Name) STREET "Ileh,01 am, <br /> AREA �i-A fit, QUAD <br /> TYPE ';W/ ^Iq _ <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way-on-the n2!15side of <br /> +•- � �. approximately feet/mile <br /> by performing the <br /> following// work (description of work) : 1_ T�r � j/ /oZ,, <br /> Zleg�l IA" <br /> Work will commence on or about / for approximately <br /> j- 1.2— 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\FBESCHDL (6/00) <br />