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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: CE IYE <br /> SAN JOAQUIN COU <br /> NTY <br /> Date ��' �(� J ZOObQ�g� v�� <br /> To: San Joaquin County JOB ##1 P T. 0 FP i(p.j 1 C R ` <br /> Department of Public Works ApN CRV <br /> Q -I EXP. DATE _ /Z-o%off <br /> J VALID- 1D-30-OCa TO &-a/-c* DRIVEWAYS <br /> (Applicant Name) STREET <br /> SOZ 2 ` AREA 57oe,eTUA/ QUAD 9S <br /> `•� u TYPE Lae$_ UTrE2, S/L�u�9L.�. <br /> (Mailing Address) FORMS <br /> S-r«N i <br /> 0, SZ 1/3 NOTE <br /> (City, State, Zip Code) <br /> 2nGi�I 7-Wn <br /> (Area Code - Telephone er) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, .cong:.truct and/or <br /> othe n roa on county----Highway Right-of-Wary-on the N S. si of <br /> of /9 . PProximately fe /mile UArX1 <br /> a A _ <br /> following w k , by performing t e <br /> g k (description of:work) : _III 2M( L <br /> r + Q <br /> Work will commence on or about Q <br /> 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 /> 4Siat4f Applicant - Ti le <br /> Date <br /> MLSTSR-PAF 88®L (6/00) <br /> i <br /> I <br />