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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 3 L4 <br /> Date OCTOBER 0,X0 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Z J /! <br /> CA \-\VcC FM\K 7V51 -\�1a VALID Zll,flla o 2 r DRIVEWAYS: <br /> {Applicant Mame) STREET Y S <br /> AREA 6►� QUPDAt <br /> TYPE %sc C� - Zxz.','r 1 <br /> (Mailing�yAddrges�s) FORMS 1,tJ1t7 <br /> 5T r�l UK T< �� b�3 NOTE <br /> (city, State, .:Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> "Ll MPIP A-1 TA[HLb <br /> VC- l <br /> The undersigned hereby applies for permission to.excavate-, construct and/or <br /> otherwise-encroach•on County_Highway Right-of-Way••oa the eide..of <br /> approximately feet/mile <br /> of by 'peY€orming the <br /> follo <br /> �l RPLAgwodesrp : rVA =iNAL GRAD <br /> GFlSIU�cF tLtV NLEDM CI <br /> UL7�2J0t S 1DCA710N5 ON EAST SME <br /> J(p�1QVALVES 771TTAL HOLE <br /> Work will commence on or'about NOVEM "p,1"y1C) for approximately <br /> O days. . <br /> I, the undersigned certify that I am the owner- of, the respective -property, or am <br /> q alified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations 'of San Joaquin C6unty and subject to <br /> inspection and approval. <br /> r <br /> Sign/a ure of Applicant Title Date <br /> 7dAST8R_P6\EBBS®L I6/00) . <br /> -•t <br />