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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1,=_ /` �iz OFFICE USE ONLY <br /> To: San Joaquin County JOB _# REF # <br /> Department of Public Works APN CR # <br /> _ EXP. DATE _ <br /> Com'I lf' \ UL��_C1 VALID TO �l!J�'S DRIVEWAYS: <br /> (Applicant Name) STREET FYI 6E,Y <br /> AREA TRACY QUAD t� <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> j '(City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> lJ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately ! . So� feet mile —z:-'c-'St <br /> of j, ;tic. `cC..� byper€orming the <br /> following work (description of work) Cov- cl u' t ''Cr <br /> Work will commence on or about / 0 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 of App icant - Title Date <br /> MASTER.PS',?EBMML (6/c0) <br />