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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dated 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # � REF # <br /> Department of Public Works APN CR" # <br /> ) � 1J <br /> EXP. DATE <br /> L—ozJ �` � f/E�� /� ii i��d VALID , - /-�Y3 TO DRIVEWAYS: <br /> (Applicant Name) STREET Yui/-?41 b' .1,�y. _ <br /> AREA-srCfU_ZJQUAD 1-5' <br /> ��cJt /' / `�✓rC�'`'��G'l/I T= �) ��C� � TYPE �iI✓/°'' r <br /> p (Mailing Address) FORMS ��� <br /> NOTE <br /> (City, State, Zip Code) <br /> L�e 3o <br /> (Are Code - Telephone Number) <br /> 4d ��, 1-16) 1i L <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> othe-rwj.se encroach�on-County Highway Right-of-Way, qn t side of <br /> /'1 t7h� approxima y fee- /mile L 7 ' <br /> of ' by "performing the <br /> foll ing work (desc ption of wor <br /> Work will commence on or about h ._? , CSC) for approximately <br /> days. <br /> I, the undersigned certify that I am t'_.e 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 /> d <br /> Signature ofF Applicant - Title Date <br /> MASTEA.PS\FEESCEDL (6/001 <br />