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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 2c�epc,_, OFFICE USE ONLY <br /> To: San Joaquin County JOB # //60 s REF # <br /> Department of Public Works APN CR # <br /> 6 ( <br /> EXP. DATE <br /> �C VALID //-2;-q'v TO //-2q-pG DRIVEWAYS <br /> (Appli ant Name) STREET IIIA OT C-YoVE _-c4P <br /> AREA Tk�Wyry QUAD IJW <br /> TYPE AER) 140 <br /> (Mailing Address) FORMS 6S1k),d -AURW <br /> NOTE <br /> 4�h32 <br /> (City, State, Zip Code) <br /> 20 9 34- 7 12(2,�- <br /> (Area Code - Telephone Number) <br /> -FIE-LD I#-*)SVec-roi__ T A VAN VOOXNE�eon 329-5/3 <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 L. =4Z_ft4 side of <br /> "L14LTTC,200f=- 'zp approximately feet <br /> ofl K—rV_._;.S'7A� V-c `r. V7 , , by performing the <br /> following work (description of work) : <br /> Work will commence on or about S for approximately <br /> Q_ 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 /> Signatur to A li ant - Title ate <br /> MASTER.PS\FEESCHDL (6/00) <br />