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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - /4 OFFICE USE ONLY <br /> To: San Joaquin County JOB # g) REF # <br /> Department of Public Works APN CR # <br /> L� / EXP. DATE <br /> U`ZKyn,�<<c.Gl << 22t�- �1�• VALID �'��-mac3 TO i 15-C, DRIVEWAYS: <br /> (Applicant Name) STREET $&Xe 6r7Y,,s3e-4/.J. <br /> _ AREA�2' ?A i el rl QUAD n/jsJ <br /> �2 CGi ��/�' Sf TYPE <br /> (Mailing �Address) FORMSi <br /> GGA// �., ] ��Z NOTE <br /> (City, State, Z:'_p 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 'ma c5-5_77 side of <br /> approximately ewi ile <br /> of Gam% /G , ,IJG�� ��/T/ y performing the <br /> following work (description of work) <br /> Work will commence on or about �'-/7-liE? for approximately <br /> /S days. <br /> 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 ap val . <br /> 77 <br /> L' <br /> Signature of Applicant - Title Date <br /> MASTER.PS\BHHSCEDL (6/00) <br />