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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date L� OFFICE USE ONLY <br /> To: San Joaquin county JOB # //DO©J REF # <br /> Department of Public Works APN Cy # <br /> EXP. DATE tv /S D <br /> U ° �pnppli�lllt <br /> L�� t�C,� VALID TO > /fir0? DRIVEWAYS: <br /> Name) STREET <br /> D r N AREA -: QUAD <br /> _j'.y �OX Ze? TYPE � P�= L�EetX' L4 <br /> (Mailing Address) FORMS <br /> NOTE <br /> 7 <br /> (City, State, Zip Code) <br /> t7 - x'4'.3 - SY;26-- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, con t eruct and/or <br /> otherwise encroach on County Highway Right-of-Way"on the side of <br /> m /a,vo em^ra( H0110approximately (ee mile <br /> of by "performing the <br /> following work (description of work) <br /> Work will commence on or about - - D for approximately <br /> /15" 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 /> accord t s, regulations of San Joaquin County and subject to <br /> I ection and proval.' <br /> S n A cant - Title Date <br /> MASTFR.PS\FSSSCHDL (6/00) <br />