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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date a OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CX # <br /> _ <br /> EXP. DATE /2•' t o(� <br /> VALID ////- -OCs TO /Z-/-off DRIVE9QAY8 s <br /> (Applicant Name) STREET lT- \c &3 <br /> AREA QUAD 5 b <br /> TYPE 7 P.Lf sC w <br /> (Mailing Address) FORMS SS /-Jdo <br /> o <br /> NOTE <br /> /YI 720 953 <br /> (City,dtate, .Zip Code) <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> R,. o , <br /> CM <br /> a C"I ':')m <br /> Cm <br /> = OM <br /> aQ <br /> x Q <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on-County. Hi Highway Right -the <br /> g Y g <br /> 5E T W Al approximately �S� ' ee mile S 0 a7 <br /> of .: . by `performing the <br /> following wo (description of work) : ,Q T_d=r -x2 Ka/Z EGD �gi✓L <br /> L ✓, tri2am C <br /> Work will commence on or about rl.3e) _D 6 for approximately <br /> % <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 /> Til C A h4 <br /> Signatur of ;Applicant - Title Daae <br /> NXSTSR.1PS\FSBSCSDL (6/00) <br />