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j-063 #-- _3O E' :-�7 2,T 9 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ OFFICE USE ONLY <br /> To: San Joac uin County JOB# 730d5"Z_S"' REF# <br /> Department of Public Works APN CR --_ <br /> { EXP. DATE <br /> VALID O /t jTCf DRIVEWAYS: <br /> (Applicant Name) STREET D Sos7':A) x <br /> AREA � QUAD j�.J <br /> TYPE <br /> (Mailing Address) FORMS <br /> ,:teaA. NOTES <br /> +,'Nty, State,Zip Code) - <br /> �l2 <br /> 2,7_1 , <br /> (Area Code-Telephone Number) - <br /> Sketch(Detailed p'Ws may be submi-lted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S.ss r.-c side of approximately 4's' feet/mile CEJ <br /> of a�C, 2JAJ3.;� L by performing the following work(description of work): <br /> S Clot <br /> 1 TW_-q v / <br /> j.ogh14�r <br /> Work will commence on or about t J - /-7-- t f for approximately s r- days, <br /> I, the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work describebcve in accordant"th the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 1 i <br /> Signature f App icant-Title Date <br /> E.PUB&SV-MMASTER.PS1ENCR0ACw1,El1T PERMITAPPLICATIGN.pOC (01/06) <br />