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APPLICATION FOR ENCROACF3CKNT PERMIT <br /> PLEASS PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # /�Q4W- REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> F Ror-essibWAL 60031RuCr0V-5 VALID TO DRIVEWAYS <br /> (Applicant Name) STREET .S/Gf1Y09 A-4-mow—.6 AREA Q= <br /> QUAD <br /> TYPE 7Eif/ fa <br /> II (Mailing Address) FORMS <br /> 2 y 2 NOTE . k 6crr-rrriy ��tY.dir�li7�- <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detail1ed''``plans may be submitted) <br /> t o 6rov,) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise. encroach on County highway Right-of War oa the lif, $ide. f- <br /> by -performing the <br /> following work (description of work) : <br /> o, ne'- a --e ". : S�'re-4 Ca.1la Qv-4y." l r. l •rkww 242P <br /> Work will commence on or about UW.I.cno• J. elan for approximately <br /> 1 O wo(ki- days. `� �+°0 8 40 <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the ownerandagree 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 /> - 2z �� 31 �g1o8 <br /> Signature of Applicant - Title Date <br /> K STER.PS\PE8SCHDL (6/00) ', <br />