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'�NS APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:/ <br /> Date _ ' �' �4 OFFICE USE ONLY <br /> To: San Joaquin County JOB # / DOS REF # <br /> Department of Public: Works APN CR # <br /> EXP. DATE G <br /> VALID TO N- c-1y? DRIVEWAYS: <br /> (Applicant Name) STREET ZZY>roG A✓E_ <br /> AREA N QUAD CC <br /> TYPE tloga Guar-r— t 6 ALi� <br /> RE <br /> (Mailing Address) FORMS Aw SS <br /> NOTE <br /> c� (Cit�y,I, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Gp w+lE.1-aT 3 <br /> p -�c,gcE F;x� ��o►.> Sops mutn ar s� ►c.rS R <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the i__.a Z( side of <br /> .�„ 6,4 approximatelyD feet/mile 9t <br /> of -,Y, L �� by performing - <br /> following work (description of work) : <br /> Work will commence on or about 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 /> Signature of Applicant - Title Date <br /> MASTER.PS\PEESCHDL (6/00) <br />