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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date rAZ OFFICE USE ONLY <br /> To: San Joaquin County JOB # t oo S REF # <br /> Department of Public works APN CR # <br /> EXP. DATE C&a1 nN uvu s <br /> D$T VALID• I- fl-ocP TO DRIVEWAYS: <br /> (Applicant Name) STREET IAN -mr 6 NRc4a <br /> AREA F:SCALo&.1 QUAD SE <br /> TYPE Tz r-oF- <br /> (Mailing Address) FORMS ,5 .mow <br /> NOTE <br /> (City, S ate, .Zip Code) <br /> 517 0 <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 /> otherwise-encroach on County-Highway Right-of-Way-on•the .,.side..of . <br /> approximately _661. ee a *P'51— <br /> of D� G4/</)g r, .,. • by performing the <br /> following work description of. work) : <br /> � ► vPmt /� _ << /'`eN'tfr <br /> 0404 14 <br /> mme <br /> e on or aha»t .iww.asaaar v;ma �+ly <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. i <br /> a � <br /> Signatur Applicant Title Data <br /> .P&\nZ9CE6L (6/00) <br /> I <br />