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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date Z 4 OFFICE USE ONLY <br /> To: San Joaquin County JOB # �W-5 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID OLS TO DRIVEWAYS: <br /> (Applicant Name) STREETt�1J� D <br /> AREAS i kN QUAD <br /> TYPE <br /> (Mailing <br /> /A'ddress) FORMS. hh1-l'G� <br /> G Tom!! <br /> (r_ 11 <br /> 11 D NOTE <br /> (City, State, Zip Code) <br /> D y17 <br /> (Area Code Telephone Number) . 0 cn <br /> Sketch (Detailed plans may be submitted) U o <br /> DC7 I�M <br /> �.�e de v pw(4 T"v N re�S �CO s� � N czr, <br /> X 1: <br /> X55 <br /> r/u�.�mcQ S .- u,lK W <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County.Highway Right-of-W ori-the _ Y side_of <br /> 2114 L A29P approximately e <br /> of _��i��45L L.�a i�/�%f� by"performing the <br /> following work (dead iption of work) : <br /> Work will commence on or'about oS`� for approximately <br /> V 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 /> dance with the rules, regulations 'of San Joaquin County and subject to <br /> inspe tion and approval. <br /> Si atu of App icant T tle ate <br /> WISTBR.PS\PSBS M (6/00) <br /> I <br />