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APPLICATION FOR ENCROACHMEI\TT PERMIT <br /> PLEASE PRINT: <br /> OFFICE 1IISE ONLY <br /> Date <br /> J1� <br /> To: San Joaquin County JOB ? / 52-(e REF �$ <br /> ppN CR` n r , <br /> D artment of Public Works o <br /> EXP. DATE �10 �VALID S Zo DR] <br /> WAXS <br /> (Applicant Name) STREET ,. T <br /> AREA QUAD _ —�* '— 'n,ntom <br /> TYPE f <br /> (Mailing Address) FORMS 3 <br /> NOTE c <br /> v/TvJJ O <br /> (City, State, Zip-Code) <br /> ( ea Code .- Tel <br /> Number) <br /> Sketch (Detailed plans may be submitted) <br /> �v 5-3 '. <br /> The undersigned hereby applies for permission to excavate, co str tt and/or <br /> of rwi �enr ch o County Highway Right-of-W y on the �� side of <br /> approximate y Q feet/ <br /> of b rfor yin�Ihi <br /> follow'ng work (description of work) <br /> Work will commence on or about P. <br /> 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 /> _^1• Tit Date <br /> Signature of —Applicant - <br /> MASTEZ.PS\FEESCML (6/00) _ <br /> I <br />