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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -Lo�Zl /OS <br /> OFFICE USE ONLY <br /> To: San Joaquin County # ,��.�, •?- <br /> Department of Public Works JOB _mss /------! EF # <br /> APN CR # <br /> CJ G. t nrL(� AS EXP. DATE _ lZ•OS•C$ <br /> / -T+T '-► VALID /!. Q. TO /2• <br /> (Applica t Name) ---77- �� '� DRIVEWAYS; <br /> STREET/�t+.IR,O �'-�� <br /> Z.3 00 e. 'Et W'f Mir RD ARE t .�-NYU AA/— <br /> } (Mailing Address) TYPE <br /> FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> +74- 4o7y <br /> (Area Code - Telephone Number) <br /> F(Detailedlans may be submitted) <br /> �ttAv�llJ6- <br /> NaFF-F- Ffc-l2m tz �¢.. ?,Avg MEIN-�aD2A F��ea 6NG��J <br /> The undersigned herebya o� <br /> applies for permission to excavate <br /> otherwise encroach on County Highway Right-of-Way on the � construct and/or <br /> o �lAlP�•hA �M�1� �_ approximately side of <br /> �aD8Rd0 fee /mile A7nR-ru <br /> following work (description of work) : by performing the <br /> Work will commence on or about Lh iUA1/ 11 O$ <br /> —D days. for approximately <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 /> 9s &�� <br /> 63�.�.� � /ofl <br /> Signature of Applicant - Title to/?.! <br /> Date <br /> MAST$R.PS\PHBSQIDi (6/00) <br />