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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 �� a07 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 3C)S�Z' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO JZ=1-40 DRIVEWAYS: <br /> (Applicant Name) STREET AQ/OLIS X&ftS <br /> Z300 F• El6µT Ml� M AREA QUAD + _ <br /> TYPE =1:M <br /> (Mailing Address) FORMS *2 __ <br /> NOTE <br /> 5'IDG6C.701�� , A � ° 2,09 <br /> 01 <br /> (City, State, Zip Code) <br /> 474- 46-7s <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SEE 9Jc.1-oSED WGS l- 3 w/ TaAfflc- pt-m <br /> Rod 1m23//DS <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the - side -of <br /> approximately feet/mile <br /> of , by performing the <br /> following work (description of work) : <br /> E /�i'rAG3461 D wGS 1-3 - <br /> Work <br /> -3Work will commence on or about 27 a'L1(s t Z,Op� for approximately <br /> —CIO 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 Appli ant - Title Date <br /> MASTER,PS\ERESCHDL (6/00) <br />