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APPLICATION FOR ENCROACHMENT PERMIT <br /> RECEIVED <br /> PLEASE PRINT: SAN JOAQUIN COUNTY <br /> Date o.o.� ��� 120 $ <br /> 23 <br /> 'UBLIC WORKS <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> -� <br /> EXP. DATE <br /> -A -- <br /> 1' VALID rXd TO v DRIVEWAYS: <br /> (App icant Name) STREET ! <br /> / > AREA Gam✓ , >QUAD /S! <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> Y---, <br /> (City, State, Zip Code) <br /> i1 J - 177- � e &LA� <br /> Ul�Ce�( <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan ay be submitted) <br /> /0539 E _q4 <br /> 31°? r, <br /> s <br /> �e <br /> The undersigned hereby applies for permission to excavate, construct-and/or <br /> othe;►ise-encroach on County Highway Right-of-Way on-the side.of <br /> i/f�,+F✓1�� � i', -? approximately feet/mile <br /> of by "performing the <br /> following work (description of work) : <br /> lip <br /> Work will commen a on or abo t Q 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 Applican - Title Date <br /> MASTBR.PS FMCEDL (6/00) - <br /> II <br />