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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dated�� ( r/ 2e ©, OFFICE USE ONLY <br /> To: San Joaquin County JOB # t�t� G ,� REF # <br /> Department of Public Works APN CR <br /> f <br /> EXP. DATE (-/M <br /> 1z&1� c_,? T a DAS T-1z(C 1 VALID •73 1- , TO J DRIVEWAYS: <br /> (Applicant Name) STREET '56r &:-Lz:>€-4,) <br /> 7 +7AREA p "4 T �)UAD NO.� ,(`jcx l F" TYPE <br /> (Mailing Address) FORMS -- <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Z-0 <br /> Sketch (Detailed plans may be submitted) <br /> A-)Wl 7-1),C)rn&'I <br /> d' r <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the tiM < <br /> ;7-1 side of <br /> t7Gt�%(L1�-i t"'k-6'4t, 4 "tc ie>ru"' fes- approximately j00 eet ile <br /> of �f L _ � 't �,� Li f,��`�lC. v ��`F� fti''r'Lol"[Y `i� L� y performing the <br /> following work (description of work) : <br /> Work will commence on cr about ALL( c cic� l�Gr 2 for approximately <br /> L <br /> days . <br /> I, the undersigned certify that I am the owner of the respective property, cr 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 /> inspec and approval. <br /> re A lic t Title Date <br /> MASTER.PS\FEES CML (6/DO) <br />