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APPLICATION FOR ENCROACHMENT PERMIT <br /> kFic fiE PRINT <br /> Date 2 6 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7_367q-3 REF # <br /> Department of Public Works APN _ CR' # <br /> S ^ EXP. DATE S <br /> t(11 VALID TO / OP DRIVEWAYS: <br /> (Applicant Name) STREET zD <br /> AREA 05a4eori/ QUAD C6 <br /> /� M <br /> TYPE 7.6GN[M ' <br /> (mailing Address) FORMS <br /> NOTE m <br /> 057-0. A 3s <br /> (City, State, :Lip Code) c <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) t7.. <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the So 6-T. side of. <br /> Rl /r_ approximately CJ ee /mile <br /> of S 4.V. by 'performing the <br /> following work '(description of work) : 9,66 ZZO7T� <br /> Work will commence on o=- about for approximately <br /> 3- _ 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 rulers, regulations of San Joaquin County and subject to <br /> inspection and approval <br /> ,,'_'- <br /> Signature of Appli t - Title ate <br /> 1X8T8A."\n8CWL (6/00) <br />