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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date o OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 0 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 5 <br /> 2x {( VALID f O TO 4 DRIVEWAYS <br /> (Applicant Name) STREET // ` 6712E&T <br /> AREA ?. f QUAD 5(0 <br /> 1 I J o � �J �� TYPE 7R 4I <br /> (Mailing Address) FORMS <br /> NOTE <br /> 0 -11- c,,.7" <br /> (City, state, Zip Code) <br /> � G � � sy9 - S -`- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> -:)FF ATW--KD 00(1 fat, STA f L. <br /> The undersigned hereby applies for permission to .excavate, cCon-stru t and/or <br /> otherwise-encroach on County Highway Right-of-Way ori-the side-of <br /> Bus . Loapproximately feet/mile <br /> of by "performing the <br /> fo lowing work (description of work) : r <br /> 0 <br /> Work will commence on or about JA�j a-9 , a-OG-) 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 /> Sign ure of Applicant - Title Date <br /> MASTER.PS\FESS®L (6/00) <br />