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APPLICATION FOR ENCROACMUNT PERMIT <br /> PLEASE PRINT: <br /> Date s f�.��� �- OFFICE USX ONLY <br /> To: San Joaquin County JOB #- //oGT REF # <br /> Department of Public Works APN CK # <br /> RT <br /> D EXP. DAT <br /> VALID' -� 0 7 TO Co-I a7 DRIVEWAYS: <br /> (Applicant Name) STREET AfY�TLC <br /> AREA STkA/ QUAD ES <br /> W 1 TYPE * T— <br /> (Mailing Address) FORMS <br /> 1 j / NOTE <br /> (City, State, Zip Code) <br /> `A' - `s`�6 <br /> I <br /> Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> S t}TTli�c1}V" k - <br /> The undersigned hereby applies for permission to .exeavate, construct and/or <br /> otherwiseencroachon County Highway Right-of-Way on-the y - side of, <br /> m' - le � 5T, approximately -- 'fid° ee / ��' <br /> - <br /> mile C <br /> Of a72p /94,4E, . by performing the <br /> following work (description of work) : <br /> Work will commence on or about for approxitllately <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 /> L1 � �, �1; .�s s ,�.�r5 n,� <br /> Signature of Applicant - Title D to <br /> MASTSR.PS\FnS®L (6/00) <br />