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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date S-/S- 0 F OFFICE USE ONLY <br /> To: San Joaquin County JOB # 730679-S REF #_ <br /> Department of Public Works APN CR # <br /> fL <br /> EXP. DATE D-'/5 <br /> T� VALID ~� TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA t: �lbn/ QUAD <br /> TYPE L'D <br /> (Masli gg4--A Address) 'l FORMS <br /> ��Gy NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans ma be submitted) <br /> �vs G I OS--b <br /> The undersigned hereby applies for permission to excavate, cons,�t}uct and/or <br /> _ otherwis encroach on County Highway Right-of-Way on the =_s side -of <br /> approximately 3c') <br /> of by erforming the <br /> following w rk (dcription of work) <br /> C <br /> C �i <br /> Work will commence on or about — — d for approximately <br /> 1.10 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 /> Signature of Applicant -Y �'P.itle � <br /> Date <br /> MASTER.FS\FEES=L (6/00) <br />