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APPLICATION FOR ENCROACHMENT PERMIT <br /> _PLEASEPRINT: <br /> Date 9 li 4 LO G OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11 o S REF # <br /> Department of Public Works APN CR ¢# <br /> j� EXP. DATE <br /> 1 l J VV <br /> C VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET U'6N�n►t(� tk�lT r _ <br /> LLie- It <br /> �� ���th �l©O JAREATocx�ror� QUAD LV <br /> ��/��V ` TYPE -Eo`Ry <br /> (Mailing Address) FORMS JS/ww 1z-29 <br /> C4 NOTE <br /> City, State, Zip Code) <br /> 14(x) GSa _ 'A _00 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission =-to excavate, constructand/or. <br /> otherwise-encroach on County Highway Right-of-Way on the NU4 SaK`4�5 side,of- <br /> WPSE approximately feet/mile <br /> of by 'performing the <br /> following work (description of work) : ' �k ",-' rg <br /> OX, 20 <br /> Work will commence on or about for approximately <br /> S 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 /> acc dance with the les, regulations of San Joaquin County and subject to <br /> in ction and appro al. <br /> gnature of Applic - Title Date <br /> MASTSR.PS\FBHSCHDL (6/00) <br /> i <br />