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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date / J� 2 <br /> JOB # 73C)1`�_3 REF # <br /> To: San Joaquin County ApN CR # <br /> Department of Public Works EXP. DATE <br /> T T DRIVEWAYS: <br /> Z 7 / �V='y /)1Z) $�.C( > VALID z b-� TO l �- - <br /> [j <br /> (Applicant Name) STREET <br /> AREA V�`CCQUAD _ <br /> Z7 dl )L6 �2 TYPE �S ORM - <br /> � ���� 33 ' ' �—'— <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> x/ 71 - Y7i.3 <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 /> �'�I?T1-� side of <br /> otherwise encroach on County Highway Right-of-Way on the feet/R '1'e r� rS T <br /> J 7^�/ p <br /> approximately / J by performing the <br /> of IJIf �/x � ' S ('1 /' <br /> following work (description of work) : <br /> C-x,96EXrSTiAtiG 1- 144. 1 . <br /> J <br /> 6j4LI <br /> 'EXEIS <br /> for approximately <br /> Work will commence on or about <br /> 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 /> Date <br /> Signature of AV licant - Title <br /> KASTER.PS\FEESCEDL (6/00) <br />