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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB # j ����� REF # <br /> Department of Public Works APN CR <br /> EXP. DATE .A <br /> �ss r pyy\VOL VALID "7,-IL?-6F, TO DRIVEWAYS: <br /> (Appli ant Name) STREET f:�04_1)7-z- <br /> �r AREA b~!'I fP LJ QUAD `S <br /> 0. ✓1'�e� TYPE "I 441. 1 — <br /> (Mai ing •Address) FORMS `" - <br /> NOTE <br /> cAqS2o6 <br /> (City, State, Zip Code) <br /> (2090 9y8 - d3o2 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See oc��J JekooY OUA .... <br /> The undersigned hereby applies for permission to .excavate, corkstrupt nod r <br /> otherwise encroach on County Highway Right-of-Way -��0.� yai 01)5 Ibt a ft of <br /> X1101 U as VJ, , 'r o�+'Way ap roximately -f-sft/mile KIpY AA <br /> of J rA Oh ) lwliovL C-hht, , b erform ng the <br /> following work description of work) : a 1ti v U <br /> ew2Y". a ►1d „�ae�l d i av v" c o r e " <br /> Work will commence on or ,about dv-czoo/e) for approximately <br /> I rvI 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 /> ignature of Applicant - Title Date <br /> MASTEA.PS\FEES®L (6/00) <br />