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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR" # <br /> EXP. DATE 0 <br /> .� , VALID 7 7 $ TO 611108 DRI73WAYS: <br /> (Applicant e) STREET N«E <br /> / AREA dAA9 CA QUAD SE <br /> TYPEl EJC <br /> (Mailing Address) FORMS <br /> ��v <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone N tuber) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, oustmaq.t and/or <br /> otherwise-encroach on County Highway Right-of-Way.,on-the 1k5 side.o ... . <br /> •' approximately Y feet mil <br /> ofZW 42-4b -per€orming the <br /> following/ work (description of-work) : -:1 r^ m <br /> Aof f?vs �tls s^ R'r,. / /� /refs <br /> Work will commence on or about 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 /> Signature o Applicant - Title Date <br /> MA9TER.PS\n3SCSDL (6/00) <br />