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APPLICATION FOR ENCROACHME1.TT PERMIT <br /> PLEASE PRINT <br /> Date21:0 5 <br /> (� OFFICE. IISE ONLY <br /> To: San Joaquin County JOE # 4 REF :S <br /> Depart n of PublicrT <br /> Works APCR' v <br /> 'EXP- DATE ISS O�c ' <br /> VPLID d TO S S DR2EW" <br /> GK <br /> AD <br /> (Applican Name) STREET , N <br /> AREAJTlU✓ QUAD <br /> 4/AO TYPE O `a* '::«C <br /> 4 rM <br /> (Mailing Address) FORMS <br /> t v <br /> NOTE <br /> City, tate, .Zip Co e) <br /> _(lea Code .- Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> w <br /> The undersigned hereby applies for permission to excavate, cons rust d/or <br /> athe 'se encroach n County Highway Right-of-Way on the sid of <br /> appy ximatel feet/ <br /> of by erform' t <br /> fpllow'n rk <br /> �,Iscrip ion of work) : /�•,Fj„ <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 /> te fie Titl^ L Date <br /> Signature a, Applicant - C <br /> MASTER.PS\FE£SC-IDL (6/00) RETURN PERMITS TO: <br /> rG&l!G <br /> JOB PROCESSONG DESK- BLD 1 <br /> 4040 Wit L WO <br /> BTpCICTOAh CA 96204 <br />