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APPLICATION FOR ENCROACffi ENT PERMIT <br /> pLE-A-S PRINT <br /> Date `� �" OFFICB USE ONLY <br /> To: San Joaquin County JOB # 11005 REF # <br /> Department of Public Works APN CR ,-# <br /> A ( EXP. DA S 3 11 of. <br /> VALID. 66 To 3111b'6 DRIVEWAYS: <br /> lieaat N KNf <br /> ST92ET MoELUMST. <br /> O t� �( AREA Soon 3Ra [TAD W/` I TYPE oRE <br /> (mailing Address.) � FORMS. $SIWW a TZ7-9 <br /> �1 I'- A- -NOTE <br /> (City, State, Zip Code) <br /> CD <br /> (Area Code - Telephone Number)_ <br /> Sketch, (Detailed plapb may be submitted) <br /> The undersigned hereby applies for permission to .excavate, co struct and/or <br /> o he�rwwi/s�e,-`encroach on County Highway Right-o£-Way oa tl e a-ide._of, <br /> approximately, _ L�� <br /> of l'YPrEesS 2111 _ b `performing the <br /> following work (description of. work) : <br /> t <br /> WorkwiU commence on or'about for approximately <br /> 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 /> -" 0 <br /> ate--- <br /> Signa re of Applicant - Ti Date <br /> .3\FKUC3DL (6/00) - - <br />