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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> • ' o�Q OFFICE USE ONLY <br /> To: San Joaquin County JOB # ? SZ-& REF # <br /> Department of Public. Works APN CR" # <br /> a _ <br /> EXP. DATE 11111,04 <br /> VALIDTO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ARES: '�Tir'� ¢Id <br /> w TYPE <br /> (Mailing Address) Q� FORMS •29 <br /> NOTE" <br /> (City, State, Zip Code) <br /> Lpn') ,l A-Z <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherw'se encroach o Cowzty Highway Right-of-'Way Way on the bkside of <br /> approximately7 feet/mzb-- <br /> Of �� `• by performing,,,the <br /> follow in work_ (d scription of w rk) : <br /> A In <br /> Let- <br /> .. ... <br /> s <br /> Work will commence on or about for approximately <br /> 6— 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 /> of (4&�q 6twW3 r 1�•t oe <br /> Si ature of Applicant - Title Date <br /> FMMJRN PEF METS TO: <br /> hIP.ST .P \FEESCML (6/00) yip �/�j,�Q• <br /> - .SOB• •n/Vi.*�7�7M DESK- SLY 1 <br /> S•OCK VNO CA <br />