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APPLICATION FOR ENCROACEMEN''t' PIM MIT <br /> PLEASE PRINT: <br /> Date <br /> O87ICE IISS OLdT,Y <br /> To: San Joaquin County JOB # 115' REF # <br /> -: Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID �'-2!- TO DRIVEWAYS: <br /> (Applicant Name) STREET//i` /dW <br /> AREA 4ix/eo QUAD ,S�f <br /> TYPE raw. & * <br /> (Mailing Address) FORMS <br /> 53 NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> 4 L-fes Q_ <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to ,excavate, cp p. 'ruct and/or <br /> otherwise, encroachon County Highway Right-of-Wa • n.•the ( side.•of- <br /> approximately ee mile <br /> of by=per€orming the <br /> following work (description of work) : <br /> [) LYN o <br /> Work will commence on or about nr 'z O 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. <br /> Signat of Applicant - Title Date <br /> MASTER.PS\FESS®L K/00) <br />