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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• - <br /> - �ar7 OFFICE USE ONLY <br /> Date ? 17 <br /> To: San Joaquin County JOB # 1100-5 REF # <br /> Depar meet of Public works <br /> APN 2 04 - 0710- a4 CR # <br /> EXP. DATE <br /> VALID S TO 9/ ,/o? DRIVEWAYS: <br /> i Q �Iv rt W <br /> ( plicant Name) STREET <br /> P.REA C a— QTJAD <br /> <, <br /> TYPEfA19t <br /> ( ailin Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) ,," <br /> ext) sok- few&� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, con truct and/or <br /> oth rwise encroach on County Highway Right-of-Way on the <br /> side of <br /> �dt y -, �z feet/mile ���`Yti <br /> approximatel <br /> r y erforming the <br /> of <br /> following work (descr:iption of work) : rL <br /> Work will commence on or about 't2 ` <br /> for approximately <br /> !�7 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 /> r <br /> Applicant - Title Date <br /> Sig Stur of App <br /> MASTER. S\F ES HDL (6/00) <br />