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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _— r OFFICE USE ONLY <br /> To: San Joaquin County JOB # I���l1) REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID /z%`i TO DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA /.-),,�/ QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> r-- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> '427)I6--D `llv't"Ec�✓E/l�E/J <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> AY tC approximately tee /mile <br /> of %�"� �f3k'/�Z� e�?i� ����'�� by 'performing the <br /> following work (description of work) : <br /> Workwill commence on or about for approximately <br /> jLa7 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 /> i <br /> i <br /> Signature of Applicant - Title Date <br /> MASTER.PS\n2SCSDL (6/00) <br />