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APP:GICATION .FOR ENCROACffiMqT PERMIT <br /> PLEASE 'PRINT <br /> Date T OFFICE USE ONLY <br /> To: San Joaquin CountyJOB ¢# IV005- REF ## <br /> Department of Public Works APN CR ## <br /> C�• � ���% _ �J �, � EXP. 'DAT /SO/o <br /> VALID. 7/o o� ' TO S DRI`TEWkYS: <br /> (Applicant Name) STREET . �T�FET <br /> �l � ■���G��(/`�(J-G•U <br /> C,9 TYPE <br /> � QUAD S� <br /> TYPE NC ,' o- 11460-c. <br /> (Nailing Address FORMS. S -94 <br /> 'NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, c nit ?ct and/or <br /> otherwise-encroach on County-Highway Right-of-Way-oa the _ c:,T�+= side.-of: <br /> approximately feet <br /> of /sem <br /> _��. a• by'performing the <br /> following work (descrition of: work) :® <br /> s t --r. .� <br /> Worms w'11 .commence on or'about for approximately <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 /> inspe <br /> ct' d approval <br /> 4gnature App Cant - Title Dat <br /> MASTSR.pS\FXW L (6/00) . <br />