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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5 / O <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # �_ _'�g REF # <br /> Department of Public Works APN CR # <br /> n 7-j -- J EXP. DATE <br /> VALID Id-1 OA3 TO J/-/'S-L1B DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Z300 AZJ AREA 67Dc.Jab11/ QUAD <br /> TYPE , -02cw-H. F-eftit Csw, aAce eeUC <br /> (Mailing Address) FORMSI-"- <br /> 5-4ekfvn C-4175-210 NOTE <br /> (City, State, Zip Code) <br /> 2o <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �7r JU -pt- a/05—of' <br /> 5� <br /> The undersigned hereby applies for permission to excavate; c nstruct and/or <br /> other encroach encroach on County Highway Right-of-Way on the Ocside of <br /> �sin approximately _ r0 fee /mile A10ry� <br /> of M;-:A�acn , by performing the <br /> following work (description of work) : 1Q7Y"� O/�¢ ars ACpyyg PRt�, <br /> p I p17 i a`X3o" &6 - &_)e O") So,1l4 S OP f tel D i��rl IFr FT p/.r<r 1-y'ronJv�l� 0D"9-0,0L c <br /> 4r CS/�, D ac,d P/4cc J/ 6i Z y"4>„�n dro+�/ s+� Or '4') G4'rd /S7 FT 10, iJ; k <br /> 07 1 <br /> Work will commence on or about Oc71aba^ 3.. &OF for approximately <br /> S 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 /> /S o� <br /> Signature of A plicant - 'Title D to <br /> MASTER.PS\FEES=L (6/00) <br />