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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEA E NT <br /> 2Gj' O OFFICE USE ONLY <br /> Date <br /> TO: San Joaquin County JOB # �� REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT <br /> C-0/vA(PA,-J`f VALID•/d �, TO /0//7/66, DRIVEWAYS <br /> (Applicant Name) STREETS_TE?' <br /> AREA S"Soc� QUAD S 5 <br /> TYPE abX=ACK Pw`z (SIM(JACO <br /> (Mailing Address) FORMS. C W-C50 o <br /> ��J �v �1�� oI.�2•-d� NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number). <br /> Sketch, (Detailed plans may be submitted) <br /> �►<'� �6 0241 <br /> The undersigned he.reby applies for permission to.excavate, co truct and/or <br /> of erwis ncro <br /> ch-on County Highway Right-of=Way as the <br /> ... side.:of <br /> approximately feet/mile <br /> of j. by performing the <br /> following work (description of work) : <br /> Work will commence on or about 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 -Applicant <br /> - Title Data <br /> MASTSR.gB\BSSSC�L (6/00) `•1 <br /> A <br />