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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r L L- l�o e OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> � q U �QY\_ + 'Vic VALID 4-tP-zgfS TO -_'-/-Z176 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> N �� TYPE '�1Tf9� QUAD -4,1 <br /> � f <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> r)nq 9g�-6a77c) t),__ <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ✓Cr L�f'ei7!CA t ��di A SYI? I Cl y (?✓@j S``CL�( ` / �t.s �� ^ <br /> nn I <br /> 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise enQroach on County- Highway Right-of-Way on the WA, e S V : side.of <br /> t jAGo J .� S ALT— approximately feet/mile <br /> of by 'performing the <br /> following work <br /> !3C . (description of work) <br /> U/� �� Cf <br /> J . - _ A <br /> I d,J Y--90TEC_7- ?J icLJ_ <br /> A) <br /> Work will commence on or about ( da (L 'S for approximately <br /> R V 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 /> �6N f6+e-77d e- Oodr'g le ._ a <br /> Signature of Applicant - Title Date <br /> MABTER.PS\PBZS=T, (6/00) <br />