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APPLICATION FOR ENCROACMd3NT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE iTSB ONLY <br /> To: San Joaquin County JOB ##_ D05_ <br /> Department of Public WorksREF ## <br /> APN CR # <br /> EXP. DAT i <br /> VALID 7 2S 07 T <br /> (Applicant Name) STREET DRIVEAYB: <br /> QUAD _ <br /> :✓C�. /�U.fi�U/� /C.� TYPE � <br /> (Mailing Address) FORMS S✓ Gf/1!J Z <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1 1) ff 4I€vii7-s <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way..on-the <br /> approximately fee L side of <br /> of <br /> /m le <br /> following work (description of work) : by *'Performing the <br /> L �IIAS " <br /> Work will commence on or about <br /> L6days. for approximately <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 /> insp \Ction and approval. <br /> l SL <br /> Si ature of pplicant - Title <br /> Date <br /> MASTSR.PS\FnS®L (6/00) <br />