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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date It� I 1 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB # # <br /> Department of Public Works APN CR # <br /> •r- 6kWEXP. DATE �%Z o-ex,:,ex,:,oV -SWVAv��, VALID (Z-2->-0 TO (v-Zo-eC, DRIVEWAYS: <br /> (Applicant Name) STREET -(C—>K-X�) 14 1-, <br /> -5. <br /> L AREA �?� QUAD <br /> d�l�D 5. � J 1���"j TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) " <br /> (Area Code - Telephone Number) <br /> c - cl qT� <br /> Sketch (Detailed plans may be submitted) r <br /> 7105'1G� (< <br /> J7A � T�� �ra✓��y Qll �11�dI.J�1� , <br /> to 51 h d vu Y! r,�JKe v, ;open )0-i Y'041, <br /> (tiJy �j t � �'� S ���� <br /> v <br /> The undersigned hereby applies for permission to excavate, constryct and/or <br /> otne,rwise encroach on County Highway Right-of-Wal[ the side of <br /> approximately ee mile <br /> of - J <br /> y performing the <br /> following work (description of work) : �rAO0.9 2L I(A <br /> =N fY o LIA'L a SNC> *1V _ <br /> Workw'11 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 /> nspection and approval. <br /> ( P,5A. <br /> Si nature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />