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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLPASE PRINT• / <br /> Date / Z 3 / OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��S REF # <br /> Department of Public Works APN CR # <br /> A E <br /> �r! D�ra?e! VALID1 31 0 6T 3 % OG DRIVEWAYS.- <br /> t�rtlraL--L'�ns <br /> (Applicant Name) STREET a r Pei STfRFET' <br /> �Q �dx AREA STV-r--3 • QUAD tJ S <br /> �g�o TYPE OCH)MG <br /> (Mailing Address) FORMS SS W W 0='?sl <br /> Q NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> `_ _ _ En�sI Non4- - <br /> N i-A° 6DR35" 50� <br /> N = <br /> o <br /> G- 3 °° <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwiseencroachon County Highway Right-of-Way-on-the side of <br /> &jarsr f_n�j 1V approximately feet/mile <br /> of C by performing the <br /> following work (description of work) : /-444- - <br /> tPl /,,r <br /> ' � <br /> Ci — a49 <br /> n!� 6 r»ftp(t <br /> SIa� Dr�i,►, <br /> Work will commence on or about _ <br /> c� <br /> days. �I�ti� <br /> �jI, the undersigned certify that I am the owner of 1 0-Aa V 0 <br /> qualified to represent the owner and agree to do tk, <br /> accordance with the rules, regulations of San JoaO <br /> inspection and approval. <br /> Signa re of Ap licant - Titld <br /> MASTER- '; P68S®L (6/00) <br />