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1 APPLICATION .FOR ENCROACMAENT PERMIT <br /> PLEASE PRINT: <br /> Date � l l OFFICE USE ONLY <br /> To: San Joaquin County JOB # /���� REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Y� VALID TO �l d DRIVEWAYS <br /> (Applicant Name) ,STREET ! <br /> AREA'TV-1✓ QUAD <br /> TYPE �ELG fir bL'� <br /> (M cling Address) FORMS <br /> NOTE <br /> (City, tate, Zip Code) <br /> - <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> L 3' -O f'6406 4 <br /> The undersigned hereby applies for permission to .excavate, onstrtict and/or <br /> ojtherwise-encroach on County Highway Right-of-Way-oh•the A. of . . .. . <br /> approximately S OD /mile <br /> of _N T _ , by "performing the <br /> following work (description of work) : _L_tQ�'TSA i L_ <br /> Work will commence on or'about for approximately <br /> 7 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 /> Signature of Applicant Title Date <br /> K&STSR.RS\FRES®L (6/00) . <br />