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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLE SE PRINT: <br /> Date /- 14 -1-) z, OFFICE USE ONLY <br /> To: San Joaquin County JOB # /'�� REF # <br /> Department of Public Works APN CR' # <br /> // <br /> EXP. DATE <br /> zze�_ X4, • VALID i-"?-Zya' TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ r AREAh'LoRFi CITY QUAD it/GaJ <br /> TYPE XrF' v12' X <br /> (Mailing Address) �j FORMS z� <br /> G4 / NOTE <br /> (City, State, Zp Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �•��C•h S Sc•�'h'1 i�7 PG <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on thel-57: side of <br /> approximately x� e ile �� <br /> of y performing the <br /> following work (description of work) : x/141 .'rte Wil'- <br /> Work will commence on or ,about for approximately <br /> /S <br /> days . <br /> 1, 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 al . <br /> Signature of Applicant - Title Date <br /> MASTER.2S\BEESC1DL (6/00) <br />