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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> � �� <br /> Date �G ( n OFFICE USE ONLY <br /> To: San Joaquin County JOB # ZJ1)/ REF # <br /> Department of Public Works APN CR' # <br /> .I �' <br /> EXP. DATE 1- 1-06 <br /> VALID i2 !Z c-i TO j- 1 y DRIVEWAYS: <br /> 1 (Applicant Name) <br /> G STREET f',�'k PLA(S <br /> lJ <br /> Ebdl IC �k AREA T�P.C 6/ QUAD �11J <br /> TYPE ,E'.( <br /> (Mailing Address) FORMS 41 -'.22 <br /> 5-)-nA'w - q<m b <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> then ise e crgA,e-h on County Highway Right-of-Way on the ST. side of <br /> c.--�- appro simat feet mile <br /> ff' r , by performing the <br /> following ork (descriptioof work <br /> 'BO, f3a�7 <br /> / a <br /> Work i commence on or about —51-11-11,10--? for approximately <br /> 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 tc <br /> inspection and approval . <br /> Signa a of Applic t - Title �� Date <br /> MASTER,PS\FE$S=L (6/00) <br />