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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t`: - � OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Q•15-.Cq <br /> VALID I 1•a4 TO Q•dS•O� DRIVEWAYS <br /> (Applicant Name) STREET C6g5�1nJA AVE <br /> AREA QUAD r— <br /> TYPE c}{ <br /> (Mailing Address) FORMS -Z� <br /> 1 , ✓t,•: r f,/ NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PI <br /> 4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the - Wl: / side of <br /> of <br /> °" approximately _ 44 C fe /mile A"� <br /> ��"��rl� <br /> by performing the <br /> following work (description of work) : F''Ver: <br /> r <br /> c�.T7 <br /> �_�k... a .,fa^Y .���':,, Y% '�:, ,<?.r.� �::�rrr'r' �+ '''x6S�,,;�_ {°'a�.vL'']'. �� c'�'� �:-{ �•�.. c1'r}cJ <br /> i5 �a <br /> Work will commence on o: about ,7:rr <br /> G` —� for approximately <br /> 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 /> Sig ture of Applicant - Title <br /> Date <br /> MAS:ER.FS\FEESCF L (5/00) <br />