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• APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �• •�.iP OFFICE USE ONLY <br /> To: San Joaquin County JOB # 730�z—Co REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 0/S <br /> VALID TO U DRIvswAYs: <br /> (Applicant Name) STREET <br /> AREA QUAD A26 � <br /> ✓ 7�/ 10 '7 TYPE <br /> (Mailing Address) p FORMS 5 � Wut�� �•� <br /> NOTE <br /> (City, State, Zip Code) m N <br /> r� <br /> _ (Area Code - Telephone Number) <br /> tt� <br /> r <br /> Sketch (Detailed plans may be submitted) _ �t <br /> (�: �jOL�S 0�✓t�J - � <br /> i ol�I Z i <br /> The. undersigned hereby applies for permission to excavate, construct and/or i <br /> otherwis encroach on County Highway Right-of-Way o the side of <br /> approximately _ feet/Wiie J7t31 <br /> of �W�l� by, exforming the <br /> following work (description of work) : <br /> Work i 1 commence on or about for approximately <br /> days. <br /> ' I <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 /> Si ature of Applicant - Title Date <br /> FMETLIRM MMR$TO: <br /> MAS .P \FEESCNDL (6/00) <br /> PQWW <br /> SM DES.- WM 1 i <br /> $TOS , 95W4 ��. <br />