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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z OFFICE USE ONLY <br /> To: San Joaquin County JOB # />�c; REF # <br /> Department of Public Works APN /`f"3--3 50°- 3� CR # <br /> EXP. DATE //^/-y7 <br /> VALID TO //-/-07 DRIVEWAYS: <br /> (Applicant Name) STREET �-+aaea AZZ <br /> _ AREA a-CQ+ /G�� QUAD _ <br /> TYPE <br /> (Mailing Addz ss) FORMS GGA!! z9 <br /> _ NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 2, S ' <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of ,erwise en roach on County Highway Right-of-Way-on the ��9's'�t-&'e5 t- side of - <br /> kD cC approximately c-� feet4 ,/V .Y <br /> of by performing the <br /> following work Idescription�of work) : Rell 4../�' <br /> v1� S ,,- <br /> Work will commence on. or about for approximately <br /> /4,) 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 /> U 2ate <br /> tur of icant - Title <br /> MA.STER.PS\ ESCEDL (6/00) <br />