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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �D/y1/T� "' OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> E" <br /> . DATE Z4 d4o <br /> bA L �/CLIZ& VALID 5127,1o(, TO 6(o DRIVEWAYS: <br /> (Applji(ca�nt Name) STP STREET P1u'sT,N 2n. <br /> IT�L`� (��(�� Od AREA t.�e1� w. QUAD <br /> 1L� _ TYPE -temAnAARY CM-D ClaStt,QF <br /> (Nailing Address) FORMS. <br /> NOTE <br /> 4s e_ '7 <br /> (City, State, Zip Code) <br /> � o � <br /> (Area Code Telephone Number)_ <br /> Sketch, (Detailed plans may be submitted) 6AP-R; cp g S 0-* <br /> Ib`AL) <br /> Rv <br /> The undersigned hereby applies for permission to .excavate, construct and/ori L�oAD 7A*545 <br /> otherwise-encroach on County Highway Right-of-Way on-the o0l,,OA14 r ... . <br /> mit/ f/1 'J.+V S O yGv tawwwwo <br /> of er€or�►ing t <br /> following work (description. f,work): NgC S <br /> w -� <br /> Work wi 1 commence on or' gout for approximately <br /> days. J <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 of Applicant Title D to <br /> CdI9IST7R.PS\EBBS®L (6/00) ���/t`�•t�•./ <br />