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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date fA-0& OFFICE USE ONLY <br /> To: San Joaquin County JOB # �3p'j`�-(- REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE IS s <br /> VALID / TO /��� DRIVEWAYS: <br /> (Applicant Name) <br /> /� STREET fd3 /Q L <br /> AREA 1!6 jrk4 QUAD E�� <br /> TYPE 79 L/- t12Lr=_ <br /> (Mailing Address) Gq FORMS -f-:$S 4-Ww R-t? <br /> n , . Ali �!?* <br /> 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/or <br /> othyrwise encroach on County Highway Right-of-Wa on the <br /> !,> � side of <br /> of japproximat I feet/ �a1 <br /> following wo k_ description of work) : by Performing the <br /> a <br /> Work will commence on or about .g <br /> for approximately <br /> - 16a 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 /> c <br /> Si ature of Applicant - Title <br /> Q� '/�u - Date <br /> MAST .p \FEESCPDL (6/00) - _•� 7UM PERWS TO: <br /> PROCES&M DESK- BLD 1 <br /> 4W Vftw <br /> 87Ol=M CN C <br />