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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• Q <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 777 REF # <br /> Department of Public Works APN CR ## <br /> VALIDDATE7 .Vo- <br /> DRIVEWAYS: <br /> (Applicant Name) STREET " <br /> .i550�1 •FR�.�10t�T' ST �\CYJ AREA 5r)e�-�,�✓QUAD •rs * <br /> TYPE <br /> �/ <br /> (Mailing Address) FORMS <br /> StOZYA_Q01 'N RJ\ C `aO ]S NOTE <br /> (City, State, .Zip Code) <br /> 301k — 'A�w—s�s <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> of rwise-encr ach on County.. Highway Right-of-Way.-on.the %00-, N side.•bf <br /> _ approximately `)M <�t[t-lz � <br /> of V'E •. • by"performing the <br /> following work (description of work) : v - ' <br /> Work will commence on or'about C �- Q5 Vor 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, re:gulations 'of San Joaquin County and subject to <br /> inspection and approval. a <br /> la <br /> Signature of A licant�e <br /> gna pp Data <br /> 1 LT=.PS\FBBS®L (6/00) <br /> l <br />