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APPLICATION FOR ENCROACMENT PERMIT <br /> PL3CASE PRINT, <br /> Date v OFFICB USE ONLY <br /> To: San Joaquin Country JOB # 11005 REF # <br /> Department of Publio Works APN __ CR # <br /> �}.� EXP. DA E 3 L O <br /> � A �t/`�;G/ �-( 1 VALID• �- q d6 TO' 1 b(e DRIV$4PAY8: <br /> licapt• Name) STREET MalLELUMtN ST. l <br /> O AREA Wo003�pt,§IIAD _ W <br /> V TYPE Some <br /> (Mailing Addrase.) FORMS 9S1WW•, R—�1 <br /> �1 /— A- � C-� � NOTE <br /> (City, State, .Zip Code) 1 <br /> 0— �. <br /> (Area Code - Telephone Number), <br /> i <br /> I <br /> Sketch (Detailed plaz}h may be submitted) <br /> The undersigned hereby applies for permission to .excavate, co s-truct and/or <br /> o herwise encroach on-county Highway Right-of-Way--oi: -the <br /> /1_Az J�Ml\e_ approxima.tel :e' L' <br /> of YPi2eSS al r h pe forming the <br /> following work (description of work) c� <br /> v <br /> Work wi 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 /> ate- <br /> Signa a of Applicant Ti Date <br /> \YSSS®L (6/00) <br />