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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT,f: <br /> Date �L'� �� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> L <br /> EXP. DATE <br /> VALID . S'-c? TO DRIVEWAYS: <br /> (A licant Name) STREET ��C�4G�%%/- FL. �% <br /> � AREA f:7 x A PJG-P' J QUAD AW:A 73 TYPE '��yG,'l ti fTT��.e: �r e=y✓w� _ �:ci_� ,� t� <br /> (Mailing Address) FORMS <br /> i NOTE <br /> 2 30 <br /> City, State, Zip Code) <br /> 1 9016 /CJ / <br /> Area Code - Telephone Number) <br /> t� 96 - 1017e <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 tie- - I sideSof - <br /> �5C approxima ely /AUCs' feel mile <br /> 604 <br /> Y7 ate', e <br /> -k-) ' Clef SY�z �i'Yt� CX /fid <br /> Work wit commenceon or about l for approximately <br /> da s. <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 rul-es, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant Title bate <br /> MASTER.PS\FEES®L (6/00) <br />