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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3 OFFICE USE ONLY <br /> To. San Joaquin County JOB # �1(�sC 075 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE - <br /> y VALID i- -Z.008 TO W DRIVEWAYS <br /> (Applicant Name) STREET T <br /> AREA L oc L ;oa". QUAD N <br /> 2P✓c <br /> TYPE �z.z�� <br /> (Mailing Address) FORMS /11 <br /> NOTE <br /> (City, State,, Zip Code) <br /> X09- �1� <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 /> other i e-encrpach n o zty. Highway Right-of-Way-on-the side.of <br /> �¢,�C approximately e mile <br /> ±pti-an of <br /> lei <br /> -' <br /> Work will commence on or about yG� - --< for approximately <br /> ,�'3� 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 /> S a <br /> Sigrfature of A lice Date <br /> MASTER.PS\HESSCHDL 6/00) <br />