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AP-PLICATION FOR ENCROACHMEI`TT PERMIT <br /> RECEIVED <br /> PLEASE PRINT <br /> Date4? <br /> OFFICE. 'USE ONLY <br /> DEPT . OF P'U LIC WORKS <br /> To: San Joaquin County JOB REF <br /> Department of Public Works AYPN CY # <br /> `EXP. DATE <br /> �/��TJ^((� VALID TO - DRIVEWAYS <br /> (Applicant Name) STREET e0&44-AQ JeD. <br /> AREA Ac14QUAD A145 <br /> el', � —�21�F TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, .Zip Code) <br /> Ll"09� <br /> (Area Code .- Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby epplies for permission to excavate, construct and/or <br /> otherwise encroach o County Highway Right-of-Way on the .50617-1 side of <br /> &ez1.ee - A . <br /> approximately /8'¢ feet -mile �(�FST' <br /> of ,�G/e& �,Qeg:z � by performing the <br /> following work (description of work) : <br /> ZE U44. <br /> nem?„�1!-Tll�1. Q� &Z/� <br /> ?9Q� d/"ASF <br /> Work will commence on or about for approximately <br /> 42 a 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 /> Z,., <br /> pproval_ <br /> Z <br /> Signature of Applicant Title Date <br /> RETURN PERMITS TO: <br /> MASTER.PS%FEES=L (6/00) <br /> JOB PROCESSING DESK- BLD 1 <br /> 4040 West Lens <br /> STOCKTON, CA 95204 <br />