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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date // / OFFICE USE ONLY <br /> To: San Joaquin County JOB # //Cy.5 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 1Z <br /> l-I��LG�GYI� G/OX.61� /A7e VALID /2 -1-114, TO DRIVEWAYS: <br /> (Applicant Name) STREET 1cT RSVE' ' <br /> AREA QUAD 4— <br /> �%�+ 11�/�/ A) A-A TYPE �csoAc►a�.��.�z <br /> (Mailing Address) FORMS <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 /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately ,/JCS feet/mile <br /> of <br /> jbY <br /> following work (description of work) : pe foe-1 the <br /> / $ <br /> Work will commence on or about for approximately <br /> z 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 /> -2�2. <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />