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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date .J/ V <br /> OFFIC$ USE ONLY <br /> To: San Joaquin County JOB # 7 3 3 REF # <br /> Department of Public Works , APN CR' # <br /> EXP. DATE G 1 D <br /> —L,�,�-i► VALID-S 1 1_57 QG TO ! a DRIVEWAYS: <br /> (Applicant Name) STREET 'q <br /> �i f AREA'°T"CGk7C� QUAD <br /> TYPE14f6E <br /> ailing Address) FORMS <br /> /J (�5 o NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; construct and <br /> otherw'se encrOaLS4 9n County Highway Right-of-Way on the -of <br /> I:rapproximately a /mile �/Q.6� <br /> Of by performin the <br /> following. work (descri tion of o k) : I f�j�, ei <br /> N <br /> N <br /> Work will commence on or about for approximately <br /> !ro f7 <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 /> N� 4C <br /> Signature or Applicant - Title Date <br /> MASTER.MFEES®L (6/00) <br />