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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 <br /> VALID• TO DRIVEWAYS <br /> (App" icant Name) STREET AANNC kW? -R*A-D <br /> AREA LATUP.6? QUAD SE <br /> TYPE -rn�cx <br /> (Mailing Address) FORMS. 6S/WL..., <br /> NOTE " <br /> r <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, .cons•truct and/or <br /> otherwise-encroach on County.Highway Right-of-Way-on-the_ side..of <br /> _AI AAa:,N.�l.�� Lne� approximately aQ.a ^,fee /mile <br /> of fl (2 r� �i by -Performing the <br /> following work (description of:work) : e- C'r- 14d"eLelcad <br /> GF,-, _ <br /> v <br /> n 7- W <br /> Work will commence on or about Z D for approximately <br /> .? <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 /> 60'-S)"e" Oki <br /> Si'gnat r of Applicant Title Date <br /> W `j 1 � <br /> IWSRBR.�8\FUGCBDL (6/00) <br /> - . <br /> Ova S i Te v4'-f CA c 1�" <br />