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APPLICATION FOR ENCROACF[MENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # iO4oS REF # <br /> Department of Public Works APN CR # <br /> _ EXP. DATE o <br /> L 1 AI/ 'Jl,►--®�'7 S' �1 r� '��" ALID 5 Zo TO l/ d!r DRIVEWAYS: <br /> (Applicant Name) STREET 4!!g- Qdrr -- <br /> /� AREA L 0J.XW_ 1 QUAD <br /> TYPE TZ.dl •l.eY Af,,041J_ e49-e4WVCf _ <br /> (Mailing Address) FORMS g*A21.) c D <br /> NOTE -+ oma+ Z <br /> I46V./ CA" r"5��� 2F <br /> n <br /> (City, State, .Zip Code) <br /> CJ <br /> (Area Code - Telephone Number) . n ^M <br /> Sketch (Detailed plans may submitted n 7° N)(� <br /> J Li Nww tom, L1 nr Dr--,,j �i' <br /> 1 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on-County- Highway Right-of-Way on-the 4VIZ-11+- . ..i ide..of <br /> approximately feet/mile <br /> of by "per-orming the <br /> following work (description of work) : CL-iJS✓ CF �jjE'D. <br /> c �T 0 AJC _ -avv <br /> Work willcommence o� or'.abe-at �00 b �0 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 /> Signature of Applicant Title Date <br /> MAST6R.PS MMOML (6/00) - <br />