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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ✓' OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. - DATE� D!o VALID qT,f!Xo TO 0 DRIVEWAYS: <br /> (Applicant Name) STREET okYr <br /> { AREA —r} Al QUAD <br /> U4N"E TYPE , <br /> (Mailing Address) FORMS <br /> Q m d a <br /> NOTA:. <br /> (City, State, Zip Code) -ra � --' <br /> (Area Code - Telephone Number) <br /> -i C:) <br /> 0 C <br /> Sketch (Detailed plans may be submitted) 2 <br /> C4 <br /> lalZA2 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oth wise encroach on County Highway Right-of-Way on,the �'Cl'ppr. side of <br /> approximate ly �`1 feet/ruc�=. -sFs1 <br /> of I performin the <br /> rk_ (description of work) : 1 _ <br /> followin wo , <br /> Work will commence on or about for ••approximately <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 /> t o� ,roo r <br /> V\FEESCHDL <br /> Applicant - Title �p��.��.( Date <br /> (6/00) U PERWTS <br /> C TO: <br /> • G <br /> GQ <br /> CA 95204 �. <br />