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APPLICATION .FOR ENCROACEMUM PERMIT <br /> ns�+a esa PRINT <br /> PL <br /> AU <br /> & T O4-1 <br /> FFICE USE ONLY <br /> JOB # I/OOH REF # <br /> To: San Joaquin County CR # <br /> Department of Public Works APN <br /> EXP. -DAT S 1S <br /> tri I VALID r /d Ofo' TO' l SGt'A DRIV8WAY8 s <br /> STREET. S `� <br /> .(Applicant Name) <br /> Sc� <br /> AREA ✓7z� QUAD <br /> TYPE- 'E,t l✓E/! ° . <br /> T`- (Mailiag Addr e) FORMS <br /> 'NOTE <br /> (City, Sbata, Zip Code) <br /> 00 <br /> -(Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) G <br /> L 00 <br /> � . <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> s�id�. <br /> otherwise--encroach'© .-County-Highway Right-of-Way-on-the <br /> . <br /> approximately /5 feet/14-Per <br /> ,. . by.performing the <br /> of f <br /> following work (descripti.on of:work) : <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 property,_ cram <br /> represent-the owner and:..agree to. do .the work <br /> qualified to representdescribed above in <br /> accordance with the rules, regulations:of .San Joaquin County and subject to <br /> inspectio and approval. <br /> rWe�i to. <br /> gna ure f plicant Title <br /> KkSTSR.FS\ ®L (6/00) <br /> .. j. <br />