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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �" (!::)4 OFFICE USE ONLY <br /> To: San Joaquin County JOS # M005, REF # <br /> Department of 1?ubl'c Works APN CR # <br /> EXP. DATE ` '%,%C> <br /> VALID c'll-C TO DRIVEWAYS: <br /> (Applicant Name) STREET _1,r4,n1 <br /> AREA X/N•TJEAl QUAD /t/�- <br /> hc7Y7�7 {�t } a TYPE :" <br /> (Mailing Address) FORMS .?'/ �� <br /> C- \�� �� , �► C GGg _/5 NOTE <br /> (City, State, Zip Code) <br /> ` y. \ (Ar Co¢e - Telephone Number) <br /> Sketch (Detailed plans <br /> }may be submitted) <br /> The undersigned hereby applies for permission to excavate i, ,_c nstrsct and/or <br /> oche wise encroach on County Highway Right-of-Wa_y on�the I�J�C�I s'de f <br /> �j approximate_ly1 _ r �fee�/mile <br /> of M Ll }�y performing the <br /> following work ( esc '_,�: on f work) : <br /> i <br /> Y <br /> Work will commence on or about '� for approximately <br /> SC �5days. <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 /> Signature o Applicant , <br /> � tle Date <br /> MASTER.➢S\P3ESCHDL f6/00i <br />