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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To : San Joaquin County JOB # 7�doL REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE ,`� <br /> VALID .27I-48 TO f /5--[ DRIVEWAYS: <br /> (Applicant Name) STREET 42*' <br /> AREA S?oC,e70+IJ QUAD <br /> J4' TYPE 4!6� � A _ <br /> (Mailing Address) FORMS 4 V v: ,P <br /> T� <br /> NOTE <br /> ����ToaJ, �• rt'SaC�� <br /> (City, State, Zip Code) <br /> 9e15 41-71 �p <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> I <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> ot1wrwise encroach on County Highway Right-of-Way on the -- 110 rle' side -of <br /> &&'q1—Y7,04' Av..2E: approximately fee /mile ZA-_)/� <br /> Of o4AWOL 0 &,/4 by performing the <br /> following work (description of work) : DLaGe l)'ogF Ateo PLeGe-0 <br /> f'c zliio'ee e go e / c <br /> fi 7 h i/X 7 'i iW ~ d O <br /> �i�ocitctr�.J Rev,)4 r.Agc- ee �/- WIPE-- A E n '�L SotE <br /> Work will commence on. or about for approximately <br /> days. ,4ec__,C41 <br /> 'W deo . <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 /> Signature of Applicant - Title Date <br /> MAS TER.FS FEES CHZL (6/CO) <br />