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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date .f.� / � (o OPTIC$ II88 ONLY <br /> To: San Joaquin County JOB # 11005 REF # <br /> Department of Public Work a APN CR # <br /> FEXP. DATE <br /> C 'v< VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET oy-AA16,6 STeeET <br /> AREA LJW QUAD Nt✓ <br /> / TYPE _EMcgOAU4 11�EtJ <br /> Mail ng Address) FORMS ss cJ-e3 <br /> r7 NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) gf <br /> G� rx0 I e too✓i P <br /> 1A/ . 4-- w009�f: q <br /> N - - <br /> 5rc✓CoNL•_�i <br /> 01 <br /> 0 <br /> The undersigned hereby applies for permission to.excavate, .construct and/or <br /> othpryrise- encroach on Co ty'ighway Right-of-W&Y-on-the /7- k/ side..of <br /> A01,!211 Uff OL d2 'g Y ,s ips S approximately feet/mile <br /> of by -per€orming the <br /> following work (description of:work) : <br /> Work will commence 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 /> inspe and approval. ` <br /> Signature oficaat Title <br /> �'v 6� C,� �6/�,�G Date <br /> MASTE•FS\F=S®L (6/00) <br /> i <br />