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APPL,ICATION .FOR ENCROACHMENT PERMIT <br /> PLEASE `PRINT: <br /> Date OFFIC$: IIS$ ONLY <br /> To: San Joaquin County JOB # A0257 REF # <br /> Department of Public Works APN CR # <br /> S ,p <br /> EXP. DA.TT _ S' s <br /> VALID oT <br /> DRIV8WAY8 cM � ET <br /> (Applicant Name) STREET. QUAD <br /> flee-TYPE TAX, <br /> CAtL <br /> (mailing /f�GE <br /> Addroza) FORMS. SsGt�w wog <br /> 'NOTE <br /> 52-1 <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plan may be submitted) <br /> -5 CVA <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on-CoLuity• Highway Right-of-Way-•on-the <br /> mo i' approximately /06 feet <br /> of gii , •. , by"performing the <br /> following work (description of:work) : <br /> / =c,J _ ^ <br /> Work will commence on or'about 0 -r for approximately <br /> a <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 /> inspectio d approval . <br /> &/73Signature f Applicant Title De <br /> lWBTSR.PS\eBss®L (6/00) <br />