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" APPLICATION FOR ENCROACHMENT PERMIT <br /> RAY"� le� � <br /> PLEASE PRINT: <br /> Date / �/ OFFICE USE ONLY <br /> F FU ILI WORKS REF # <br /> JOB # <br /> To: San Joaquin County CR # <br /> Department of Public Works APN <br /> J EXP. DAT O <br /> (`�rGi� 1'� �[ S'�(�i:'7 n:s�? 1r7 "► VALID:'°�!9 TO G DRIVEWAYS: <br /> (Applicant Name) STREET rw <br /> AREA QUAD __ <br /> S�(rX7 <br /> 41f Ic1 �� (J TYPE S! <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, .Zip Code) <br /> 7s(:2 <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) �ll.QS ?moo- <br /> 10j <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Wa on the �.�t�' . <br /> s id06•o f <br /> � <br /> 4,•� ✓�, t� '' aPProximately �d ee /mile <br /> s4 , <br /> by "performing the <br /> following work (description of work) : <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 /> Si tura of Applicant ritle Date <br /> MASTM.$S\FBBS®L (6/00) - <br />