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.APPLICATION FOR ENCROACHMENT PERMIT <br /> PL'EASF���',INT-• <br /> Date l —` ,! OPFICS USE ONLY <br /> To: San Joaquin County JOB #mss REF # <br /> Department of Public works APZ.T <br /> L r6 EXP. DATE _ <br /> C _ VALID TO DRIVEWAYS: <br /> (Applicant Namm'e) STREET NT (N p* _ <br /> 60X W ,r U AREA. arWO QU..4D .6k) <br /> TYPS <br /> (Nailing Address) ` FORMS ,5-9 yvw <br /> 5Go 5 �Q.L'�� tr� (3�.J 0(47 NOTE <br /> (City, State'*'Zip Code) <br /> �%3 ` 1- I - [Ai�taIs <br /> (Area Code - TeIephone Neer) <br /> Sketch (Detailed plane may be submitted) - Se-e- PIWIS <br /> Post-it"'Fax Nate 7671 Dare/^ �; pIA e <br /> TO yFrom <br /> Phon@# 'S (bons 11 <br /> Fgx# Fax# <br /> The undersigned hereby applies for permission to excavate, construct and/or -* 50- Ck*4441e� <br /> otherwise encroach on County Highway Right-of-Way on the side of Ito- <br /> approximately feet-/mile <br /> of , b performing the <br /> following wa 1c (description of 11W" <br /> , 1bcZ+rb►1 <br /> Work will commence on or about for approximately <br /> days , <br /> T, the undersigned certify that T 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 axed approval. <br /> Signature of Applicant - Title Date <br /> MnSTRA.MFEEMML (6/60 <br />