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APPLICATION .FOR ENCROACHMENT PERMIT <br /> PLEASE 'PRINT: <br /> Date <br /> 1p OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # . <br /> Department of Public: Works APN CR ' # <br /> /. ;A60 FF EXP. DATE 7 l0 6(0 <br /> � 1� LI TL1` A�Pr VALID 7 t olo• TO' 7 ato DRIVEWAYS <br /> (AppliEaat Nairne) STREET /d 1W_ T <br /> r AREA QUAD <br /> TYPE TAMP: L <br /> (Mailing Address). FORMS. --' <br /> 7Z C' �5 NOTE <br /> (City," State, Zip Code) <br /> (zo �= <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be 'tted) N � <br /> D <br /> -p o - <br /> -4 C= Z <br /> n = 0M <br /> -_ _ <br /> oa <br /> a v, 2 <br /> --- = _ <br /> The undersigned hereby applies for permission to .excavate, con"ruct and/or <br /> otherwise-encr�h-on County. Highway Right-of-Way -n-the aid <br /> �..bf - <br /> __ /d ST• approximately t ( "�tlfet/mile <br /> of 49F I t "# ' y.'per€orming the <br /> following work (description of:work) : <br /> SAM 6 Ii ij7(l�i= Z" iu `F DisDtkY <br /> .. cTu�c <br /> Work.will .commence on or'about ��4 n 11� p1�`� vu�� �5�� !o 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 /> inspection and approval <br /> Si atu a of Applicant Title Da" e <br /> MaTIOL.ps\MUCEDL (6/00) / <br />