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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date � OFFICE USE ONLY <br /> To: San Joaquin County JOB # \lobs- REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID f 9 cX/TO C7,- DRIVEWAYS: <br /> (Applic nt Name) STREET 11/tiALE Y 57PE36T <br /> AREA SZo 7"oN QUAD ES <br /> aw�j7 . TYPE 71JUac u <br /> (Mailing Address) FORMS Ss/ww 12-29 <br /> � NOTE <br /> (City, State, Zip Code) <br /> 02 0S -�/G-9s�y� <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 ,-e5y-3 T" side of <br /> approximately -306, feet/makz- �Sou7 of Y-n s- by performing the <br /> following work (description of work) : GS'a�✓c�- <br /> Work wiles 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 /> Signature o Applicant Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />