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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1/ ' OFFICE USE ONLY <br /> To: San Joaquin County JOB # w�Z'� _ REF # <br /> Department of Public Works APNCR # <br /> EXP. DATE <br /> VALID S T '7h DRIVEWAYS: <br /> (Applicant Name) STREET ; &eZA <br /> AREA <br /> OST C.A TYPEVT <br /> G %LF E <br /> (Mailing Address) FORMS <br /> NOTE- <br /> CD <br /> . C? <br /> �Ia < <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) CD <br /> Sketch (Detailed plans may be submitted) <br /> a <br /> loi 31tz <br /> The undersigned hereby applies for permission to excavate, .co struct and/or <br /> oth rwise encroach on County Highway Right-of-Way on .the . side of <br /> approximately —feet/m=*s <br /> of <br /> by performing the <br /> fo lowing work (description of work) : bob t <br /> Abd <br /> Work will commence on or about for approximately <br /> If-20 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 /> 6A.6? 6twjbr <br /> Si ature of Applicant - Title Date <br /> RETURN PERMITS TO: <br /> tMST .P \FEESCEDL (6/00) PMC <br /> JOB PROC+ESSM DESK- BW 1 <br /> 4040 Wink LVW <br /> STOC KTON, CA 95204 <br />