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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 04- 2 Z- ZDCa� OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��'� !ly 3 REF # <br /> Department of Public Works APN CR ## <br /> h I/, / l <br /> EXP. DATE <br /> CSI.&1J�.U2epq!S (AT•$T M- / VALID TO `y' 8 i DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <_ <br /> 2:30 0 E t 16AT M 11.E RD TYPE Z <br /> (Mailing Address) FORMS Z <br /> NOTE <br /> (City, State, Zip Code) <br /> �1-Oq��}- 4fis`7•S <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A•iTA(:::1AW <br /> c I�'rGP <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway -Right-of-Way on the rUl�E�3� side -of <br /> . AIP-0 AC 055 0i.61) approximately 42!5 feet/w&-kQ <br /> of by performing the <br /> following work (description of work) : QU- ZE5 4" "C 'l, LDER69c00fl APPRX. <br /> 3 -11 nEPTA . <br /> Work will commence on or aboutMA�/ t2 �'M69 - for approximately <br /> (7 <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 /> 4 <br /> Signature of Appli t - Title Date <br /> MASTER.PS\FEES(HDL (6/00) <br />