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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLS XX PEI=: <br /> • °pA # 79•lS <br /> Date 1 R ��®� OFFICE USE ONLY <br /> To: San Joaquin County JOB #_1��! / REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATE A9__/_11n8 <br /> CA�1 FORNIR �1�( ATTR S�E�V <br /> VALID 3�5-e6 TO Z2_-Z_-0E__ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 1S50S' t\M AREA f97zr.;t1MA✓ QUAD _ <br /> TYPE ELAII i I <br /> (Mailing Address) FORMS Z-Z- <br /> r <br /> aO 3 NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plazas may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach.on County-Highway Right-of-Waty-oa•the side._of <br /> �FZfl'Fi�rpa9�� __ approximately feet/mile ^ <br /> of +. by"performing the <br /> following work (descri tion of work) : <br /> N <br /> Work will commence on or'about 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 to <br /> inspection and approval.',,,C'Lz.- <br /> VIE R57 <br /> Signature of Applicant - Title Date <br /> 1aSTAR.PS\►ffi®L (6/00) - <br />