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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USF ONLY <br /> To: San Joaquin County JOB #. 7&77 REF.# <br /> Department of Public Works APK <br /> M—F, SKM Ita .M.1 TO . DRIMAYS: <br /> (Applicant Name) STREET <br /> \550 fin( :Vy,o(O\T SIT. -*t OBJ AREA � Qum _ &)S <br /> TYPE29 <br /> (Mailing Address) FORMS <br /> s�c.��a� • � `�5a03 NOTE . <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> m NO tn. <br /> p � <br /> � ca <br /> 01 N c <br /> o <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroach•on•County•Highway Right-of-Klay•oa the ^" gide•,of. - •• . • .• <br /> of <br /> _ approximately feet/mile <br /> --rel forming the <br /> Poll w' work (description of•w rk) <br /> Work wi commence on or Lt A. <br /> _ Q <br /> f <br /> daysapproximately <br /> . • <br /> I, the undersigned certify that I am the owner of, the respective property, or ami <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the :rule regulations 'of San Joaquin County and subject to' <br /> inspection and approval. Olo-\,a-•ob <br /> Signature of Applicant Title Date' <br /> 4?S\F886®L (6/00) - .. <br />