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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `� f � OFFICE USE ONLY <br /> To: San Joaquin County JOB # � Z-�D REF # <br /> Department of Public Works APN CR # <br /> ` EXP. DATE l <br /> VALID 2 2e O(p TO 1 DRIVEWAYS: <br /> (Applicant Name) STREET * <br /> girye AREA QUAD <br /> C, OQ TYPE -Pff/?AkWG 4f 901 " <br /> —�---1 (Mailing Address) FORMS <br /> IIn , ` NOTEYv5 A 0 <br /> (City, State; Zip Code) <br /> (Zvi !I A'Z - I&ZA <br /> (Area Code - -Telephone Number) <br /> Sketch (Detailed plaits may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> Q, approximately feet/=C= �07 n <br /> of _ �►�`-�1�LJ by performing the <br /> follow in work (d scription of work) : j <br /> �� <br /> Work will commence on or about for approximately <br /> days. , <br /> I, the undersigned certify that z 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 /> ns-pection and---aAP-neva-1.--.. - - -- - — --..__ <br /> i <br /> 16f �J' �rl � 2- trpb <br /> Si ature of Applicant - Title Date <br /> RETURN PERMITS TO: <br /> t4AST .P \FEESCIOL (6/00) POM <br /> JOB PROCESSM DESK-BLD 1 <br /> 4040'~UVW <br /> STOCKTON, CA 9SW4 <br />