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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> /D"RV VALID - TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> !iAREA OGKtr/A/ QUAD <br /> TYPE c <br /> / / 1 <br /> (Mailing Addre s) FORMS <br /> (�-�t'K✓D P l c/f ( T-� -3 NOTE <br /> (City, State, Zip Code) <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 /> otherwise encroach on County Highway Right-of-Way on-the L 4- side of <br /> oa "� 72-J approximately T2 _ feet mil 140 <br /> of -ter R-r u by 'performing the <br /> following work (description of work) : <br /> - <br /> Work will commence on or about for approximately <br /> -- S <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 a d approval. <br /> Signature Applicant - Title Date <br /> MASTER.PS\FEES®L (6/00) <br />