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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> JOB # MODS REF # <br /> TO: San Joaquin County 4M .. # <br /> Department of Public Works APN <br /> EXP. DATE D 1 Z4�o <br /> VALID L9 TO DRIV8NAY8: <br /> (Applicant STREET 7 ,t�/ELLA <br /> QQ AREA.4� QUAD Zkj: <br /> TYPE T,g.6 NGH - <br /> (Mailing Address) FORMS. sz <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) v N <br /> 74 21-/ <br /> v. o _ <br /> -' <br /> f7 . <br /> mop o� <br /> -� >r„ <br /> -� o c, <br /> c = C=M <br /> ..� Z< <br /> m � Z <br /> The undersigned hereby applies for permission to.excavate, c ns- uct and/or <br /> otherwi e-�oach on County Highway Right-of-Way-on-the aid .o <br /> pproximatel f et/ ile O ' <br /> �' rC eY orm'11g th <br /> follow' wor ( escription Lof:work) : © � <br /> Work will commence on or'about 4.s74 oo for approximately <br /> y 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 /> G <br /> Signature of Applicant Title ate <br /> MASTER.?S\FESS®L (6/00) - . <br />