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APPLICATION FOR ENC.ROACEMEN'f PERMIT <br /> PLEASE PRINT <br /> Date 1� �` OFFIC$ USE ONLY <br /> To: San Joaquin County JOB # /h� REF # <br /> Department of <br /> De Public Works APN CR # <br /> p Cgl <br /> EXP. DATE <br /> �dJU�O� � f rC •�C�d Com VALID c�-3o- � TO /0 DRIVEWAYS: <br /> (Applicant Name) ` STREET AAREA <br /> TYPE !lam n L'L s t <br /> (Mailing Address) FORMS <br /> / ^ t NOTE <br /> c �//. L� �`• 95 7Y7 • <br /> (City, State, .Zip Code) <br /> C> c p- 99 q t y ?Q9: 313 G �3 <br /> Ca - <br /> (Area Code - Telephone Number). <br /> Sketch, (Detailed plans may be submitted) <br /> S v cid AIQ /A) /�- =U-" z 7 7`i <br /> AA4cJ� C J <br /> (24W 01 <br /> The undersigned hereby applies for permission to. xcavate, .construct and/or r � <br /> otherwiee=encroach on County Highway Right-of-Way-on bhe• 13aTN side5'of <br /> f/ e . Q ��Ng approximately feet/mile <br /> or <br /> by 'Perf - -A the <br /> following ork (description of:work) : , T <br /> d <br /> Ila iQ <br /> Work will cgMence on t om-:: C.-� do�A 4/ for approximately <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 /> Date <br /> Signature of Applicant itle �QN a]�o`Pfteo:�<,- <br /> )QB=.FB\n=CHDL (6/00) <br />