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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 2,1 ® OFFICE USE ONLY <br /> To: San Joaquin County JOB # �� �`� 3 REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE 1 <br /> VALID 1 TO /AQ/02 DRIVEWAYS: <br /> (Applicant Name) STREET CS ISD, <br /> Z oo �j d AREA 5"f�N QUAD X <br /> ��� A r GJ t TYPE 610 <br /> (Mai ing Address) FORMS <br /> A NOTE <br /> (City, State, Zip Code) <br /> 6209) 47q- L1051 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Z-o <br /> Av <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> - otherwise encroach-on Coun i <br /> y � - ghwa <br /> y--Right-of-�Wa o �dQ6-}- <br /> Phe. � �, - side -of <br /> U.q L�. �)�Co aapproximately feet/mile <br /> of ( 4 by performing the <br /> following work (description of work) : '' v-Y\ oLQ_ 0 YA <br /> L <br /> Sti\ - - <br /> Work will commence on or about I Q5 10(afor approximately <br /> (fir]_ C c:, 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 /> 106 <br /> k4nature of Applicant - Title Date <br /> MASTER.PS\FEES®L (6/00) <br />