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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County JOB # /1060.5 REF #��- o��I SV <br /> Department of Public Works APN Z4,? JSa -33 CR # <br /> EXP. DATE '' jf - <br /> VALID TO S- / o DRIVEWAYS: <br /> (Applicant Name) STREET <br /> c AREA E ca/a QUAD ISF- <br /> �7W sKff'Ll TYPE 5 <br /> (Mailing Address) FORMS _IZ Z W <br /> NOTE <br /> ( itC y, State, Zap Code) <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 /> otherwise-e croach on County Highway Right-of-Way-on-the _ side-of <br /> approximately fee /mile �07 �7 ' <br /> of by 'performing he <br /> folowi work (description of work <br /> A 07, 6 e- <br /> Work will commence on or about for approximately <br /> r/ <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 /> 4sig <br /> io d approv <br /> a of Appl nt - Title y Date <br /> KUTER.PSWFBESCEML (6/00) - <br />