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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /I c7Dg OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of :Public Works APN CR # <br /> EXP. DATE <br /> VALID -I:40 TO '��/g -C� DRIVEWAYS <br /> (Applicant'Name) STREET <br /> AREA QUAD <br /> j;� vi G rfv >Z 7 TYPE <br /> (Maili g Address) FORMS p /t "�,h �' - � � , ��� ,�'_z <br /> NOTE ` <br /> (City, State, Zip Code) <br /> 1 11 =-i�/e; - C:.)So <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach_/n County Highway Right-of-Way on-the / / side of <br /> C'"��� approximately feet/mile <br /> of Ariz e��t !�rrt,� by erforming the <br /> following work (description of work) : A) <br /> Work will commence on or about for approximately <br /> 1.') 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 anci,,approval. <br /> / i( <br /> ' 0(i i3 <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FERSCHDL (6/00) <br />