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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date U� OFFICE USE ONLY <br /> To: San Joaquin CountyJOB # d�! � ' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE le-1 D <br /> VALID 15-e TO /!J/DS DRIVEWAYS: <br /> (Applicant Name) STREET raI A&310D Atgtg <br /> / AREA Tk�/✓_ QUAD 6_ <br /> TYPE r'ALL 1aif2E <br /> (Mailing Address) FORMS �C <br /> NOTE <br /> (City, State, Zip Code) <br /> zc <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> C/9w00'p <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway-Right-of-Way on the - �C7GrTl�/ side -of <br /> [(�'1GJooD approximately /Ob ee /mile (rJ�S7 <br /> ofby performing the r q <br /> following work (des(:ription of work) : t�/ate Lie,<�'x 3-!s�jr .S-Zs"` SZt c-'e'14 ear J-;, yam, xs� <br /> 'Al on 2.06"X' % �fr'��l`!� ,,.J A,,f 71b c:4,mi, e4we �wfl�d tvhi i < - Trv��,i� tO <br /> %4,,4 SO NI- /.,� 5;74 w,l.d rte a&" A" Ca 4: .; 6�vo/z rte, Pnt'o <br /> (eriYS GJ,Ii lam �u•xC .4?, � -4 Q 14efAe IVJ/ kt Of Of e�i✓�'le�. �� ✓P'rGeS �eSr�/r� /"� or �nr7o' <br /> Work will commence on or about /S- OF for approximately <br /> s'O 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 /> n✓�Y.No r J�l/ c��'' <br /> Signat re of Applicant - Title Date <br /> MAS':ER.PS\FEESCHDL (6/00) <br />