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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date i 1-so 1 W- OFFICE USE ONLY <br /> To: San Joaquin County JOB # �3Q�(/ REF # <br /> Department of Public Works APN Cy # <br /> EXP. DATE / <br /> �A-� ef- VALID iP / �T l DRIVEWAYS: <br /> (Applicant Name) STREET LJT a * <br /> _ l - i AREA 57z Ce kma n/ QUAD <br /> 3UZ7 T- - r i�',yy� t TYPE SPG✓GE I*r <br /> ( ling Address) FORMS ,+, <br /> � NOTE r'A �l2 ' <br /> (City, State, Zip Code) <br /> cq (-k­�ti x- ( t d <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; cons ruct and/or <br /> otherwise encro ch on County Highway Right-of-Way on the ci side of <br /> ��ea approximately `� f_eet/mile hem t` <br /> ofra.��rsY� by performing the <br /> follow'ng work (description of worig <br /> l � f iD <br /> - <br /> Work will commence on or about for approximately <br /> _ �%n 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 /> gnature of ppli nt - TLOe Da e <br /> PIASTER.PS\FEES= (6/00) <br />