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APPLICATION FOR ENCROACEMENT PERMIT <br /> ELEASE PRINT <br /> Date 1 D^ OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Il-of-or„ <br /> 0Ng Q.% t N Q VALID 10-W- TO 11-01-0(y DRIVEWAYS:. <br /> (Applicant Name) STREET CLAIroW AVe. <br /> Q AREA nr-ockron/ QUAD Gy5 <br /> TYPE <br /> (Mailing Address) FORMS ��+N� Q"2 <br /> Ll NOTE <br /> (City, State, Zip Code) <br /> - <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> 4 <br /> 213 �/a <br /> The undersigned hereby applies for permission to .excavate, .construct and/or <br /> otherwise-encroach on County Highway Right-of=Way-oa•the side..of - <br /> approximately Z(� eet ile <br /> of oc� J y performikt the <br /> following work (description of work) : r a : t!A%Ll 4LS2w.tti ",al'l. <br /> �ect X101 1 � cR <br /> Work will comm�nce on or about 10- 2.G--b for approximately <br /> �a • 3© 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 /> inspectio roval. <br /> Signature of Applicant- Title Date <br /> MASTER.PS\FESS®L (6/00) <br /> �4\ <br />