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APPLICATION VOR ENCROACMdENT PERMIT <br /> =is�n ag `PRINT <br /> OPTICS. USE ONLY <br /> Date �..--•-- <br /> JOs # /IOOS REF # <br /> To: San Joaquin County CR # <br /> Department of. Public Works APN <br /> EXP. DATE <br /> VALID lP TO D DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> AREA ' QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 12 <br /> (Area Code Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> �/�.yvt �QCt f•G /r.4, (/�/�i/' 7/v /'L,"cpv�C �Ic �OvtCv►G�G � S <br /> of" � / C/Y 5 S�-� � r�i✓'--� . X44•.�Vic.- mac oar �"`-� <br /> a <br /> I <br /> The undersigned hereby applies for permission to .exoavate, construct and/or <br /> aide..,of;... . ._. <br /> otherwise-encroach on County.Highway Right-of-Way. a othe feet/mile <br /> approximately . <br /> d� <br /> of [ Cro'S itlaCa.�+�hr+r 4d. , by.per orming the <br /> following work (description of:work) : .w <br /> y <br /> for approximately <br /> Work will commence. on or'about <br /> days. <br /> I the undersigned certify that I am the .owner of.the respective pro erty,,inr am <br /> qualified to represent..the owner and :agree. to do .the work described ove <br /> accordance with the rules; regulations �of .San Joaquin County and subjlect to <br /> inspection and approval. <br /> Date <br /> Signat a of plicant - Title <br /> KL8TSR.FS\rMCHDL (6/00) <br />