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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> nate a3 03-- <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JON # _ S REF # <br /> APN CR # <br /> I N�L EXP. DATE /D OS a8 <br /> VALID 9 b TO DRIVEWAYS/o a 4 <br /> (Applicant Name) STREET flee l <br /> AREA UAD S W� w <br /> (Mailing Address) <br /> , l FORMS <br /> ( I , <br /> v "` R j q� �(1- C1 5 ` 7c) NOTE <br /> (City, state, Zip Code) <br /> �L,► <br /> (Area Code - Telephone Number) <br /> Failed plans may be submitted) <br /> e� <br /> The 'unders net hereby applies for permission to excavate, con�t.r,�et and/or <br /> otherwise encroach on County Highway Right-of-Way on theC, )-I, <br /> If „ rec - approximately r, _ 2 c� /mi1e side <br /> ����'1 <br /> following work (description of work) : b'Y 'per€ormin the <br /> �� J cJcS O Y S 3 380 <br /> Work will commence on or about �apy� <br /> one- days for approximately <br /> 1, the undersigned certify that I am the owner of the respective property, <br /> qualified to represent the owner and agree to do t' or and <br /> t work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval . <br /> gnat re •f Applicant - Title 3 'U <br /> Date <br /> MASTBR,eg\FPPOC}[DL (6/00) <br /> 7n ;TO 7nkmq i C I TInh17J n,)r+c h7CGf}Q1-,C,G17 ril Ll '} T 1007 /77/QM <br />