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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ` /rte C/ I7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # //KDS REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> � �y �✓�/°J2 VALID A0- TO /-/-D DRIVEWAYS: <br /> (Applicant Name) STREET OGtlJ9.+2 �T�, <br /> �? AREA EGTA QUAD �G1J <br /> l� A� TYPE <br /> (Mailing Address) FORMS <br /> - l✓// D�'7 4��,� 95~Z6 7 NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> r <br /> n� �41 �•d�a �� l <br /> The undersigned hereby applies for permission to excavate, const ct and/or '86re= <br /> of erwise en ro h on County Highway Right-of-Way-on the side of - <br /> r' pproximate y feet/miww <br /> of by erforming he <br /> followi wog (description of work) : r <br /> -45.4 4 �� <br /> r y <br /> I <br /> or will commence on or about for ap roximate y <br /> days. <br /> I, the undersigned certify that am the owthe respecti 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 /> __,p <br /> Signature of Applicant - Title Date <br /> MASTEA.PS\FB&SCHDL (6/00) <br />