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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ZI I��� OFFICE USE ONLY <br /> To: San Joaquin County JOB # /00-75 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID 12 / O TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA i'�.�N QUAD <br /> TYPE /tet <br /> (Mailing Address) FORMS SS plc/✓s -'�� <br /> NOTE <br /> (City, State, Zip Code) <br /> D\L� ) - LasIZ <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 Q,;ft eu"4' side of <br /> M" '�s V 0 " 3') , approximately feet/mile <br /> of -r 1J s. OrTC-) I , by performing the <br /> following work (description of work) : - lf '„ <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 /> Signatu'r'e of Applicant - Title I D to <br /> MASTER.PS\FEESCIDL (6/00) <br />