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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 136 7!—3 REF # <br /> Department of Public Works APN C . # <br /> EXP. DATE D <br /> VALID G / TO Z111,96. DRIVEWAYS: <br /> (Applicant Name) STREET /tfi9iJv '�T <br /> �3D � AREA =TKA/ QUAD FS <br /> 'glTYPE ?W&)C1,r' <br /> (Mai ng Address) FORMS oe G? <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> rn <br /> 'O _O D" <br /> rn 2 <br /> ?a <br /> C M <br /> xr O <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of--Way on the -_639 UZ side -of <br /> - - approximatel e /mile <br /> •SND �, � �� � - y performing the <br /> following work (description of work) : �21 <br /> rsv <br /> H u <br /> OL <br /> Work will commence on or about - _T"Nle / `-� for approximately <br /> - S <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 /> Signature .V�nsf Applicant - Title Date <br /> MASTn.PS FEssC119L (6100)�� -... <br />