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APPLICATION FOR ENCROACMdENT PERMIT <br /> PLEASE PRINT• <br /> Date 3�ZZ�OCa OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11005 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> J 0 ✓1 Torr e,Ir) VALID Z2�dCo TO 7 / UV DRIVEWAYS <br /> (Applicant Name) STREET _,�JrAICID/V <br /> AREA �MeAl QUAD <br /> TYPE 5,,mvjoz e <br /> (Mailing d ess) FORMS. �GJ�, 2 N <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submi ted) <br /> The undersigned hereby applies for permission to .excavate, constru t and/or <br /> otherwise-encroach on County Highway Right-of-Way.-on-the BAST ideo of <br /> A36approximatelyn-��t�e '.e� <br /> h "performing the <br /> following work description of. work) Mpari T�c�u>e1�� fn ren} o� feStc�a�oc <br /> Work 11 commence on or'about 3 2 6l0 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 /> Sign re of Applicant Title Date <br /> NASTBR.PS\FSBS®L <br /> I <br />