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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # /®C)5 REF # <br /> Department of Public. Works APN CR # <br /> � EXP. DATE /0 <br /> 0.& T <br /> / � i �/ VALIDDYLlJ� 6TO /p <br /> a7 DRIVEWAYS: <br /> �1 orn n I (Applicant Name) STREET (qtr/aaig 5 � <br /> , � / JJ AREA ��A " QUAD <br /> �j G 71 W. l\In�Y Oi'1 0 4 TYPE -A-& re-ozo, ,�''a�,c� &03flrs. <br /> (Mailing ddress) FORMS �/LdcJ <br /> � <br /> v <br /> NOTE al�' , ��► �►sa 41( 2 <br /> (City, State, Zip Code) <br /> C� o 7- Z/-7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> S ee- c--A e- (Z/ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of by performing the <br /> following work (description of work) : _j`e rxr4 J?"--1 CGosv-,e o <br /> t+vo, v rcN <br /> v a 'o At B.sof `0o m /a Z <br /> p v <br /> Work will commence on or about /O/�-CLO 7 for approximately <br /> 2 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 /> Signatur f Applicant - Title <br /> MASTER.PS\PEESCHDL (6/00) <br />