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R <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , OFFICE USE ONLY <br /> To: San Joaquin County JOB 4 /.3OSZr(e FIEF <br /> D artment of Public Works RAN CR n <br /> EXP. DATE 8 0(0 <br /> VALID 3 Zo O - TO / ap DRIVEWAYS: <br /> (Applicant Name) STREET iGoi�ER 5T. <br /> /� �� AREA �"Ot./cTar/ QUAD �5 <br /> [_ ,,/{y) * <br /> a TYPE S �E .t BDL <br /> ( ailing Address) FORMS <br /> - -- -- — - KoTE.(5 <br /> ___— -- <br /> (City, Statfe, Zip Code) <br /> {Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 5� �� 4 � �. <br /> The undersigned hereby applies for permission to excavate, co truc and/or <br /> oth ise encroach on Cc ty Highway Right-of-Way on the � side of <br /> approximately feet/=tM6 <br /> Of Y. by perfo ing the <br /> ) <br /> following work (des„criptio of work : <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 n agree to do the work described above in <br /> accordance ith the rules, regul tions of San Joaquin County and subject to <br /> inspectio and appro <br /> Signature 0- Applescant - Ti 'a Dates <br /> MASTER.PS\FEESMML (6/00) <br /> i <br />