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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r ` 3 �� V OFFICE USE ONLY <br /> To: San Joaquin County JOB # /l REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE !!5_774; <br /> � - <br /> CF VALID TO DRIVEWAYS: <br /> v (Applicant Name) STREET G ifiP 16P * <br /> AREA QUAD <br /> C��1��,. Sf <br /> TYPE <br /> (Mailing Address) FORMS ' <br /> r1 c,"J C A q 3 37 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, contruct and/or <br /> otherw'se-encroach on County Highway Right-of-Way on-the ecG5. side of <br /> �cS4in R app oximately /00 ee mile C4 5'f <br /> of 4A " f Coy�t e� L� �+vp dt►c� �trs�c:c '. �.�. by .per ormin.g the <br /> following work (descript'on of work) : �/ c�I� f (� '01-t /�£''" cieTe- fVci�is'rv�(SS�v�; <br /> (,yo.. �- u�rHe� L,�• .Tc.Q /�"! atf <vt G�K� ��"'S O� f'� �1 Ir6cP5! <br /> Work will commence on or about Q fir: 1S-4 1, ALU 1c' for approximately <br /> Z 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 /> -eV- 2-U u U <br /> Signature of Applicant Title Date <br /> MASTER.PS\MS®L (6/00) <br />