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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE 'PRINT: <br /> Date 00 , <br /> OFFICE USE ONLY <br /> TO: San Joaquin County JOB REF # <br /> Department of Public Works APN CR . #k <br /> EXP. DATE 7-/616Y6 <br /> VALID- 6-27-0.. To <br /> DRIVE4PAY8 <br /> (Applicant Name) STREET . l .P .41).1 E,Qie/ A <br /> V3• C�c�1�S �. 10�- ARE] 7,�J y� _ QUAD ! <br /> TYPE <br /> (Mailing Address) FORMS. ._n��, <br /> T12G�]"O C f, . NOTE <br /> �`1v� <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed laps mai <br /> .� be submitted) .� <br /> Li=) �+R�• �tr+onJ <br /> J+ <br /> t+ o n <br /> + C= <br /> 070 <br /> QG -1-5 i4T! u C� <br /> The undersigned hereby applies for permission to .excavate, construct an o X <br /> otherwise-encroach on County Highway Right-of-Way--on-the (', ' <br /> approximatelyee /ate <br /> of �.��5-C�2 b -perfo irig the <br /> following work (description of:work) : t�E x 71 e fE0 — <br /> ( 0 i i LC- - t--P-1W <br /> 71 <br /> Work_will commenceon or'about <br /> ys fj jj 5 da for approximately <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 L.the work described above in <br /> accordance with the rules, rgulations �of San Joaquin County and subject to <br /> inspection and approval <br /> _C I <br /> Si�Tc natuLe <br /> re of Ap lican Ti tae r <br /> Date <br /> - <br /> ►91S18R$S\8sssc'F�L (6/00) <br />