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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> _ �` y- o <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # %/�D�>� REF # <br /> Department of Public Works APN Cy # <br /> EXP. DATE ,! <br /> C , VALID TODRIVEWAYS: <br /> o(Applicant Name) STREET A49 Re, <br /> AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS``- <br /> ONOTE <br /> +-- <br /> 9S <br /> ,L O8 <br /> p � <br /> (City, State, Zip Code) <br /> 209- 1iL13- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> BIewk)i lik <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwiseencroachon County Highway Right-of-Way on-the _ U aide.of <br /> C72Q approximately -T- aR.On Sfeet/mile <br /> of r, by 'performing the <br /> following work description of work) o'� q Lfn2 K,_jj(�o a <br /> SI !u PI Li!L n UA. S-ee '6"t=� <br /> c <br /> Work will commence on or about - 1—O for approximately <br /> 3 a 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 approval. <br /> pazl_�' LA (zi a <br /> S gnature of Applicant - Title Date <br /> MASTER.PS\nESCHDL (6/00) <br />