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APPLICATION FOR ENCROACEMIENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> Jos # 1/� REF # <br /> To: San Joaquin County CR # <br /> Department of Public Works APN <br /> r <br /> EXP. DATE — <br /> ( VALID 5 JW TO / DRIVEWAYS: <br /> v <br /> (Applicant N se) STREET `� GI/O �G, 9 �/L <br /> AREA AWIPZ-,6: QUAD NW <br /> �a TYPEeHI�JG <br /> r (Mailing Address) ( FORMS 29 <br /> Lcx-sl NOTE <br /> (C State, Zip Code) <br /> (Area Code - Telepho:ae Number) . <br /> C7 � <br /> Sketch (Detailed plans may be submitted) <br /> �^ � vm o D <br /> =C <br /> A-H In 'rim ox <br /> StnJ L'D��E2 ci -�c o <br /> Mt <br /> 0 <br /> The undersigned hereby applies for permission to .excavate, cAnstruc�andij ,yLv <br /> e.-.of. ro'CW6- <br /> otherwise-encroach on Count Highway Right-of-Wa a th feet/elrii� <br /> approximately r <br /> PP �' by=p orming the <br /> ,. , <br /> lowing work (descri tion of44: ork} : <br /> Work will commence on or'about <br /> 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 /> Signa re of Applicant tle Date <br /> ®L (6/00) <br />