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APPLICATION FOR ENCROACM ENT PERMIT - <br /> PLEASE PRINT: <br /> Date OFFICE USB ONLY <br /> To: San Joaquin County JOB # �, � l "3 "F # <br /> Department of Public Works APN CR' # <br /> ST� EXP. DATE <br /> t�L VALID TO - DRIVxNaZSs- <br /> (Applicant Name) STREET * -' <br /> AREA QUADV <br /> c/�7 C- G' r-1 1 tilt l,E U-t3�1 I� TYPE ; <br /> (Mailing Address) FORMS ; �Lw, .�r71)• <br /> NOTE <br /> i eXxTo�•.t � �l� 2-� O <br /> e <br /> (City, state, Zip C6del <br /> (2 CP _7Q <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) o u, <br /> rn o D. <br /> Z <br /> p f�1 C70 <br /> rp <br /> tr <br /> • N � <br /> C tC rr, <br /> C1 { <br /> I' co <br /> O C.1 <br /> � N <br /> The undersigned hereby gpplies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way n the -•FwArST side of <br /> _S ],L-O R.- LL-Q approximately q Zees/mile _5MAT1 <br /> of•) _� T 7AGW by performing the <br /> following work (description of work) : 'V1 IT o o`Jt <br /> •J A tJ§E1j2 C.A o rS 1 (i eL'. plc <br /> Work will commence on or about o for approximately <br /> 30 <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 /> Signature of Applicant' - Title Date <br /> MtSTDt.GS\niSQDL (6100) <br />