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APPLICATION FOR ENCROACE[MENT PERMIT <br /> PLEASE PRINT: <br /> Date 1tJ �^ © OFFICE USE ONLY <br /> TO: San Joaquin County JOB # I L 00S REF # <br /> Department of Public Works `` APN CR # <br /> EXP. DATE <br /> V I L VALID-,10�/ti cG TO 1® rG DRIVEWAYS.- <br /> (Applicant Name) STREET 40RJ;_: IN(a t o' <br /> AREA 51o'c Acr t QUAD CC- <br /> TYPE <br /> Com-+ n <br /> (Mailing Address) FORMS WWF -JF Z7. CGct- ?/Cw_v/f01 <br /> NOTE <br /> (City, .State, Zip Code) <br /> ( Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, .consltrd/or <br /> otherwise-encroach on Highway Right-of=W 9}�s�the side Q - <br /> �-� \ p ely `v feet/mile V ` I <br /> ofU_R " <br /> _Trr:forming the <br /> foil ow'n work (desc2Jiptkpn of wor <br /> Work ommence 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 Ti a Date <br /> MhSTSR.VS\PBBSCHDL (6/00) <br /> i <br /> . i <br /> • 1 <br />