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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1! Z ! r �/�� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> L� TEXP. DATE 4917 <br /> xCG,VAki q �—`'LL!5 VALID a41/ TO -��= p DRIVEWAYS: <br /> (Applicant Nam c- ' Vt���) STREET W - * <br /> AREA QUAD <br /> VG X fy�.S TYPE <br /> ( <br /> (Mailing Address) 1 FORMS 57/L�l,�_tet/a ' 2 <br /> 5-f <br /> NOTE <br /> 0 C <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/or <br /> otherwise encroach on County Highway Right-of-Way on the GiS sideo <br /> S f-lctw f approximately i-`f feet/mile No r <br /> of rKe-Vtt)V1:f' by performin the <br /> following wo k (description of work) : _ .` r6 <br /> ( Y <br /> Work will commence on or about c _) - for approximately <br /> l 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 /> Signa re of Applicant - Title Date <br /> MASTER-.PS\FEESOML (6/00) <br />