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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 3-- Lei OFFICE USE ONLY <br /> To: San Joaquin County JOB # '��� � REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATES /5 <br /> ��i" 1 C/4 4� / VALID 4-1-N4 TO DRIVEWAYS: <br /> (Applicant a3 NameES <br /> ) STREET elk Joar E� <br /> M JUL AREA iJ.( AORJ�E QUAD <br /> sTYPE <br /> (Mailing Address) FORMS LzJW - <br /> 5 MC w-Y'0 *JL 'CA 9.5aR/_0 NOTE <br /> (City, State, Zip Code) <br /> ao 9 - q7q - q 7S``1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A-TTAC H F-1 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of - <br /> N Cmf. MWT 5ST- approximately s-0 feet/j&!J i& N/O1.'7M <br /> Of AU&V S`I`�4 a _. by erforming the <br /> following work (description of work) - <br /> orr CO A C,esa/(� WtT'N <br /> C r 4W G iAJCr A�C.S Q 1 z" Co N u i T- Ts po <br /> 71) b L<_v o N /,)It Ca <br /> Work will commence on or about U`/' CC for approximately <br /> 3 G 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 /> Sign re of Applicant - Title Date <br /> MASTEA.PS\FESSCHDL (6/00) <br />