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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> y <br /> Date . �4 OFFICE US8 ONLY <br /> To: San Joaquin County <br /> JOS #% REF # <br /> Department of Public- Works APN CR' # <br /> EXP. DATE 10- <br /> �— <br /> VALID7'l-1_� TO 10- " a t V DRIVEWAYS: <br /> (Applicant. Name) <br /> STREET <br /> AREA�j4�r n,T�l� QUAD <br /> TYPE <br /> (Nailing Address) FORMS j_ - <br /> NOTE <br /> (City, State, Zip Code) <br /> Cry-2.- C= "_ y <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans 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 kj=\:f�+ side of <br /> approximately feet/mile <br /> of by performing the <br /> following work (description of work) <br /> Y�-L­A( <br /> C <br /> Work will 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 /> i ction and approval. <br /> Signature of Applicant - Title Date <br /> MAST=.P8\P231SCEDL (6/30/,00) <br />