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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date111- /DS <br /> OFFICE USE ONLY <br /> TO: San Joaquin County JOB #_ /fQQs REP # <br /> Department of Public Works APN CR # <br /> EXP. DAT d <br /> LOrt •STC!C T7��j,�_ VALID -�/3'(�� 0 DRIVEWAYS <br /> (Applicant Name) STREET <br /> /86 AREA7X2gc S/ QUAD _ <br /> TYPE f <br /> (Mailing Address) FORMS <br /> -c�U l NOTE <br /> -2o,7- (City, State, Zip Code) <br /> �.z,�u r� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, c nstruct and/or <br /> 0otherwise croach on Count-y Highway Right-of-Way on baa7 .. <br /> "J Sa3 rCru �,ea4,u 7-L,,,;� si de5o f <br /> approximately X300 feet/mile Es}�; p F- <br /> of NIT Nou•rr.• �rI.—J�4Y _ <br /> following work (description of wor byper€orming the <br /> ,� 11 P ) `<os L�ry.c r l,.,vcT- <br /> �ND W r DF.✓ Al (; �C n <br /> �N y 7T $E <br /> L r ,ei v iPi ttc <br /> T , D <br /> 40 u -AJ- <br /> Work <br /> will commence on or about .a TIE'iPiv<y <br /> AF6 -� Fri s—��«� .0 <br /> days.A.',4 fC r r- orapproximately <br /> (�c F,',u.+c. �iTR�P�.uc�) 11r 5 ; .z <br /> 7�i2iurcrr <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 /> Signature o Applicant - Title <br /> Date <br /> MASTER.PS\FEESCIML (6/00) <br />